Uncovering Hidden Pathologies: Upper Gastrointestinal Endoscopy in Patients with Symptomatic Gallstone Disease

Abstract

Background:

Gallstone disease (cholelithiasis) remains one of the most frequently encountered conditions in surgical practice, especially in females over 40 years of age. While laparoscopic cholecystectomy is widely accepted as the standard management for symptomatic gallstones, a significant proportion of patients continue to experience persistent gastrointestinal symptoms even after surgery. This has raised concerns regarding the potential coexistence of upper gastrointestinal (GI) pathologies that may be misattributed to gallstones. Upper gastrointestinal endoscopy (UGIE) is underutilized in this context despite growing evidence of its diagnostic and therapeutic relevance in symptomatic patients.

Aim:

To evaluate the spectrum of upper gastrointestinal endoscopic findings in patients diagnosed with symptomatic gallstone disease and to determine the role of preoperative UGIE in improving diagnostic accuracy and patient outcomes.

Methods:

This was a prospective observational study conducted in the Department of General Surgery at tertiary care teaching hospitals in South India .   Eighty-one adult patients (>18 years) with radiologically confirmed cholelithiasis and presenting with either typical or atypical upper abdominal symptoms were included. Exclusion criteria comprised acute abdomen, CBD stones, obstructive jaundice, pancreatitis, gallbladder neoplasms, and previous hepatobiliary surgery. All patients underwent detailed clinical assessment, abdominal ultrasonography, and preoperative upper GI endoscopy. Endoscopic findings were documented and categorized as normal, inflammatory, ulcerative, or malignant. Where indicated, biopsy and rapid urease tests were performed. Appropriate medical therapy was initiated based on findings, including H. pylori eradication or proton pump inhibitor therapy. Patients with malignant lesions were excluded from cholecystectomy and referred for oncological management. Data were analyzed using SPSS v28; associations between clinical symptoms and endoscopic findings were assessed using the Chi-square test.

Results:

The study population comprised 81 patients, with a female predominance (68.75%, male-to-female ratio: 0.45:1). The mean age was concentrated between 31 and 60 years, with the highest incidence (26.25%) in the 41–50 age group. Abdominal pain was the most universal symptom (100%), followed by dyspepsia (56.25%), bloating (33.75%), nausea (21.25%), and vomiting (4.93%). Comorbidities included diabetes mellitus (28.4%), hypertension (22.2%), and hypothyroidism (13.58%).

Ultrasound findings revealed multiple gallstones in 59.3% of cases and solitary stones in 15%. Gallbladder wall thickening >4 mm was seen in 55% of patients.

UGIE revealed abnormal findings in 32 patients (39.5%). The most common was H. pylori-positive gastritis (23.46%), followed by gastritis without H. pylori (4.94%), peptic ulcer disease (2.47%), duodenitis (1.23%), and dyskinesia of the esophagus (1.23%). One patient tested positive for H. pylori on rapid urease test. Patients diagnosed with gastritis or ulcerative lesions received medical treatment prior to surgery. In two patients with malignancies, surgical intervention was withheld, and oncological referral was made. Conclusion:

Routine preoperative upper GI endoscopy should be considered in all patients presenting with gallstone disease and atypical or dyspeptic symptoms. It aids in identifying coexisting inflammatory or ulcerative GI conditions that may mimic biliary colic. Timely medical management of these conditions can result in significant symptom relief and may avert unnecessary surgical intervention. Incorporating UGIE into the preoperative workup promotes a more rational, stepwise, and patient-centric approach, ultimately improving outcomes and reducing morbidity associated with unwarranted cholecystectomy.