A Review of the Management of Cholelithiasis at Buraydah Central Hospital in the Qassim Region, Saudi Arabia: A Cross-Sectional Study

Cholelithiasis is the most common cause of gastroenterological hospitalization. Given this significant risk, perfectly managing cholelithiasis is crucial to reduce hospitalization. Unfortunately, we have not found a study on a review of the management of cholelithiasis in Saudi Arabia. Therefore, we aim to evaluate cholelithiasis concerning demographic features, presentation symptoms, predisposing risk factors, laboratory features, complications, and outcomes in the Qassim region. This cross-sectional study of all patients with a radiological diagnosis of gallstones, whether symptomatic or not, was diagnostic in 2022. The researchers fielded a preformed data collection sheet for each patient from the hospital system. Data obtained were entered into a spreadsheet and analyzed using SPSS Statistics version 23.0 (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.). A total of 526 patients were included in the study. Most patients (116, 22.1%), were aged 38-42. The finding also indicated that most patients were females (397, 75.5%), while males were only 129 (24.5%). The study also found that the difference between women and men presenting complaints of fat intolerance and right shoulder pain was statistically significant. Women were 100 (84%) and men were 19 (16%) for fat intolerance, while for right shoulder pain, women were 50 (89.3%) and men were six (10.7%). The p-values were 0.014 and 0.011, respectively. Further, there was a statistically significant difference in terms of the complaints presented by the patients between the complicated and non-complicated cases of abdominal pain (p=0.001), nausea (p=0.001), vomiting (p=0.001), change in urine and stool color (p=0.001), and right shoulder pain (p=0.001), among other complaints (p=0.001). The study concludes that most patients affected by cholelithiasis are individuals in the middle age group, with women being more affected by the disease than men. Further, among the individuals affected by the disease, the majority of them were overweight and obese. On the other hand, the study concludes that the majority of patients who suffer more from cholelithiasis are affected mainly by other associated diseases such as hypertension, hypothyroidism, and diabetes mellitus. In conclusion, many factors may contribute to gallstone formation and the outcome of the disease and surgery. Therefore, the study recommends that health workers offer tailored education, especially targeting the highlighted factors found in this study, to create awareness of disease control measures in the general population. Also, keep in mind these factors when dealing with patients who complain of abdominal pain.


Introduction
Cholelithiasis, otherwise called gallstone disease, is a disease characterized by the formation of stone(s) in the gallbladder from the aggregation of a mixture of water, cholesterol, bilirubin, and bile [1].Cholesterol is derived from food, while bilirubin and bile are derived from the breakdown of the haem molecule in red blood cells.Usually, an equilibrium exists between these constituents, which are then maintained in a soluble state.However, disruptions of this equilibrium lead to super-saturation and precipitation of calcium hydrogen bilirubinate, the nucleation and polymerization of bile pigments, and the deposition of inorganic salts like calcium carbonate and phosphate.Gallstones can lead to a wide variety of clinical conditions, including acute cholecystitis, chronic cholecystitis, obstructive jaundice, and acute pancreatitis [2].The majority of cases are asymptomatic and discovered incidentally, and it has been reported that approximately 20% of individuals experience symptomatic gallstone disease [3].
In a study in Riyadh in 2017, 8.6% of the study population had gallstone disease.They found out that the risk factors associated with gallstones in Saudi Arabia were aging, female sex, weight gain, diabetes mellitus, liver functional enzymes, and lipids [4].With a gallstone prevalence rate of 11.7%, Abu-Eshy et al. reported that female gender, previous complaints of pancreatitis, and previous family cases of gallstone were strongly associated with gallstone disease, while age, blood pressure, coffee and cigarette intake, excess weight, diabetes, total pregnancies, and the use of oral contraceptives were to a lesser extent associated with the disease [5].In another study to determine the factors contributing to the development of chronic cholecystitis in the senile population of the Kingdom of Saudi Arabia, the prevalence of the disease was about 7%.Similar to other studies, this study also reveals disease associations with age, gender, diabetes mellitus, and body mass index.This study further suggests that thyroid dysfunction and high blood pressure are associated with chronic cholecystitis [6].
Helicobacter pylori (H.pylori) causes infection in the mucosal layer of the stomach and gallbladder, and it is strongly associated with the formation of stones in the gallbladder.Guraya et al. [7], in Saudi Arabia, reported that H. pylori might be a potential risk factor for cholelithiasis.It has also been suggested that treatment of H. pylori infection is greatly needed to avoid the formation of stones in the gall bladder [2].
Previous studies had noted the relatively increased risk for gallstones among patients who had bariatric surgery and inferred that bariatric surgery contributes to excessive and rapid weight loss, which could be a significant risk factor for the development of cholelithiasis [8][9][10].This has led to recommendations for using prophylactic bile acids, like ursodeoxycholic acid, in the early months after surgery to avoid cholecystitis and gallstone formation [11][12][13].
Reda et al. observed seasonal variation in the prevalence of acute cholecystitis among 161 patients, with higher rates in the summer (38%) than in the winter (22%) or autumn (18%) periods [14].Moreover, Cariati posited that increasing age was a significant risk factor for both women and men [15].Khazraei et al. reported that women have a higher prevalence of gallbladder stones than men [16].The increase in prevalence of gallstones among women is thought to be more frequent due to obesity, which is higher in them [17].In a case-control study, Ahmed et al. opined that genetic and environmental factors, like industrialization, cause obesity and fertility problems in women and may lead to gallstone development [18].Besides obesity, other factors implicated in the etiopathogenesis of gallstones include female, 40, fertile, fatty, and fair (the so-called 5 "Fs" of gallstone disease), family history, and poor eating habits [19].Finally, a report from China indicated that an active lifestyle, reduced weight gain, and less use of spices and fried foods would be beneficial in decreasing the prevalence of gallstone formation [20].
Even though cholelithiasis is the most common cause of gastroenterological hospitalization [21], we have not found a study on a review of the management of cholelithiasis in Saudi Arabia.Therefore, we aim to evaluate cholelithiasis concerning demographic features, presentation symptoms, predisposing risk factors, laboratory features, complications, and outcomes in the Qassim Region, Saudi Arabia.

Materials And Methods
This cross-sectional study was conducted at Buraydah Central Hospital, in the Qassim Region, Saudi Arabia.All patients diagnosed with cholelithiasis in 2022 were included in the study.The selection of samples was made by convenience sampling.The inclusion criteria were all patients reviewed and managed for gallstone disease with a radiological confirmation of stone or post-operative presence of stone in the gall bladder.The exclusion criteria were those who had uncompleted files.The sample size was calculated using Cochran's formula, with an expected prevalence of 50%, a confidence interval (CI) of 0.95, and a margin of error of 5% [22].Consequently, a minimal sample size of 384 patients is needed to achieve the required CI.Our study includes a total of 526 participants to ensure accuracy.
The retrospective chart review of patients with cholelithiasis who were seen at Buraydah Central Hospital in 2022 was performed.Data were obtained from hospital medical files.We extracted data on age, gender, height, weight, comorbidity, presentation symptoms, previous surgery, lab result, type of surgery, other intervention if any, complication, and duration of hospital stay.The needed data were entered in a Google form (Google LLC, California, USA) and accessed by the researcher only to ensure data safety.Ethical approval was obtained from the Qassim Research Ethics Committee (approval no.607/45/5833).SPSS Statistics version 23.0 (IBM Corp. Released 2015.IBM SPSS Statistics for Windows, Version 23.0.Armonk, NY: IBM Corp.) was used to analyze the data.Furthermore, categorical data were used for descriptive statistics and were given as numbers, percentages, and frequencies, whereas continuous data were shown as mean, mode, and standard deviation.We utilized t-tests and chi-square to evaluate the significance of the relationship between the variables.P-values less than 0.05 were considered statistically significant.

TABLE 1: General characteristics of the participants (N=526)
The data has been represented as N, %, mean ± SD ^ Some patients have more than one comorbidity and presenting complaints BMI: body mass index, WBC: white blood cell, RBC: red blood cell, HGB: hemoglobin, ALT: alanine transaminase, AST: aspartate aminotransferase, ALP: A majority of patients reported abdominal pain, followed by vomiting, nausea, and fat intolerance, respectively.Changes in urine or stool color resulted in the lowest reported symptoms (Figure 1).Bariatric surgery was the most common factor associated with 41 people.Other factors with a lower frequency included previous cesarean section (16 people), postpartum (15 people), appendectomy (nine people), and lactation (seven people) (Figure 2).Among comorbidities, hypertension ranked highest, followed by diabetes, hypothyroidism, and pulmonary disease, respectively.The lowest reported comorbidity was cardiac disease (Figure 3).

FIGURE 1: Presenting complaints FIGURE 2: Associated factors of cholelithiasis FIGURE 3: Participants' comorbidities
Table 2 shows that the difference between female and male participants presenting complaints of fat intolerance and right shoulder pain was statistically significant.Women were 100 (84%) and men were 19 (16%) for fat intolerance, while for right shoulder pain, women were 50 (89.3%)and men were six (10.7%).
The p-values were 0.014 and 0.011, respectively.Additionally, the difference between women and men in terms of presentation of the symptoms was statistically significant: for recurrent (women (161, 80.1%), men (40, 19.9%)), first time (women (108, 69.2%), men (48, 30.8%)), p-value 0.007.The associated factors (lactation, postpartum, previous cesarean section (CS), appendectomy, and bariatric surgery) were shown to have a significant difference for women and men (p=0.007).More so, there exists a statistically significant difference between women's and men's lab results for WBC (p=0.009),RBC (p=0.001), and hemoglobin (HGB, p=0.001).Finally, a p-value of 0.007 indicated a statistically significant difference between female and male types of surgery.

TABLE 2: Association between gender and clinical characteristics (N=526)
The data has been represented as N, % * A p-value of <0.05 is considered statistically significant ^ Some patients have more than one presenting complaints CS: cesarean section, WBC: white blood cell, RBC: red blood cell, HGB: hemoglobin, ALT: alanine transaminase, AST: aspartate aminotransferase, ALP: alkaline phosphatase, MRCP: magnetic resonance cholangiopancreatography, ERCP: endoscopic retrograde cholangiopancreatography Table 3 shows that the difference between the BMI categories of the participants presenting complaints of fat intolerance and changes in urine or stool color was statistically significant.The most prevalent was overweight (50, 42%) and obesity (19, 33.6%) for fat intolerance, while for changes in urine or stool color, overweight was 22 (62.9%) and obesity was eight (22.9%).The p-values were 0.014 and 0.011, respectively.Further, the associated factors (lactation, postpartum, previous CS, appendectomy, and bariatric surgery) were shown to have a significant difference in the BMI categories of the participants (p=0.001).In addition, a p-value of 0.013 indicates a statistically significant difference between the method of surgery and the BMI category.

TABLE 3: Association between BMI category and clinical characteristics (N=526)
The data has been represented as N, % * A p-value of <0.05 is considered statistically significant ^ Some patients have more than one presenting complaints CS: cesarean section, WBC: white blood cell, RBC: red blood cell, HGB: hemoglobin, ALT: alanine transaminase, AST: aspartate aminotransferase, ALP: alkaline phosphatase, MRCP: magnetic resonance cholangiopancreatography, ERCP: endoscopic retrograde cholangiopancreatography Table 4 shows that the difference between the complicated and non-complicated was statistically significant hypothyroidism comorbidity (p=0.003).Further, there was a statistically significant difference in terms of the complaints presented by the participants between the complicated and non-complicated abdominal pain (p=0.001),nausea (p=0.001),vomiting (p=0.001),change in urine and stool color (p=0.001),right shoulder pain (p=0.001), and other complaints (p=0.001).Additionally, the difference between the complicated and non-complicated regarding the presentation of the symptoms was statistically significant (p=0.001).More so, there exists a statistically significant difference between the complicated and non-complicated lab results for WBC (p=0.001),ALT (p=0.001),AST (p=0.001), and ALP (p=0.001).There was also a statistically significant difference in how surgery was done, the type of surgery, and other interventions employed between the complicated and non-complicated.This was indicated by p-values of 0.001, 0.019, and 0.001, respectively.The data has been represented as N, % * A p-value of <0.05 is considered statistically significant ^ Some patients have more than one comorbidity and presenting complaints BMI: body mass index, CS: cesarean section, WBC: white blood cell, RBC: red blood cell, HGB: hemoglobin, ALT: alanine transaminase, AST: aspartate aminotransferase, ALP: alkaline phosphatase, MRCP: magnetic resonance cholangiopancreatography, ERCP: endoscopic retrograde cholangiopancreatography

Discussion
The study reveals that a total of 526 respondents participated in the study.undergo laparoscopy as the most significant type of surgery.Nevertheless, 33 participants (6.3%) indicated upper endoscopy as an additional intervention.Among the complications of the surgery, abdominal pain was the most prevalent (11, 2.1%).The average duration of the hospital stay days was 2.74, with a standard deviation of 2.79.These findings were similar to those acquired by Gehlot et al. in their study, which noted that the majority of the participants treated for cholelithiasis were characterized by overweight and obesity.At the same time, many were middle-aged individuals [23].
The study also found that the difference between female and male participants presenting complaints of fat intolerance and right shoulder pain was statistically significant.Women were 100 (84%), and men were 19 (16%) for fat intolerance, while for right shoulder pain, women were 50 (89.3%)and men were six (10.7%).
The p-values were 0.014 and 0.011, respectively.Additionally, the difference between the women and men in terms of presentation of the symptoms was statistically significant for recurrent (women (161, 80.1%), men (40, 19.9%)), first time (women (108, 69.2%), men (48, 30.8%), p-value of 0.007.The associated factors (lactation, postpartum, previous CS, appendectomy, and bariatric surgery) were shown to have a significant difference for women and men (p=0.007).More so, there exists a statistically significant difference between women's and men's lab results for WBC (p=0.009),RBC (p=0.001), and HGB (p=0.001).Finally, a p-value of 0.007 indicated a statistically significant difference between female and male types of surgery.These findings are in line with the findings obtained by Tuna et al. in their study, which noted that a large number of patients characterized by cholelithiasis symptoms were female as compared to male patients, with most of them having recurrent symptoms [24].
More so, the findings reveal that the difference between the BMI categories of the participants presenting complaints of fat intolerance and changes in urine or stool color was statistically significant.The most prevalent was overweight (50, 42%) and obesity (19, 33.6%) for fat intolerance, while for change in urine or stool color, overweight was 22 (62.9%) and obesity was eight (22.9%).The p-values were 0.014 and 0.011, respectively.Further, the associated factors (lactation, postpartum, previous CS, appendectomy, and bariatric surgery) were shown to have a significant difference for the BMI categories of the participants (p=0.001).In addition, a p-value of 0.013 indicates a statistically significant difference between the surgery method and BMI category.These outcomes were similar to the outcomes obtained by Gökçe et al. in their study, which noted that the middle-aged group is more affected by cholelithiasis since the majority have no control over their eating habits, which is a contributing factor to the emergence of cholelithiasis [25].
Further, the study indicates that the difference between the complicated and non-complicated was statistically significant for hypothyroidism comorbidity (p=0.003).Further, there was a statistically significant difference in terms of the complaints presented by the participants between the complicated and non-complicated abdominal pain (p=0.001),nausea (p=0.001),vomiting (p=0.001),change in urine and stool color (p=0.001),right shoulder pain (p=0.001), and other complaints (p=0.001).Additionally, the difference between the complicated and non-complicated regarding the presentation of the symptoms was statistically significant (p=0.001).More so, there exists a statistically significant difference between the complicated and non-complicated lab results for WBC (p=0.001),AST (p=0.001),ALP (p=0.001), and ALT (p=0.001).Finally, the study findings reveal a statistically significant difference in how surgery was done, the type of surgery, and other interventions employed between the complicated and non-complicated.This was indicated by pvalues of 0.001, 0.019, and 0.001, respectively.These findings agree with the findings acquired by Al-Saad et al. in their study, which noted that cholelithiasis patients suffering from other serious diseases, such as hypertension and hypothyroidism, have more severe symptoms of cholelithiasis than patients who are not affected by other diseases [26].Also, according to the findings obtained by Deepak et al. in their study, comorbidity significantly influences the level of cholelithiasis management as it involves the management of other associated diseases, which sometimes makes it hard to manage the primary disease [27].
This study has several limitations, including a small sample size, which limits generalizability to a larger population.Data collected from the hospital system limited our ability to obtain additional information, such as family history and smoking.Additionally, H. pylori and other risk factors were not included in our study.

Conclusions
The majority of the patients affected by cholelithiasis are individuals in the middle age group, with women being more affected by the disease as compared to men.Further, among the individuals affected by the disease, the majority of them fall under the categories of overweight and obese.On the other hand, the majority of patients who suffer more from cholelithiasis are affected mainly by other associated diseases such as hypertension, hypothyroidism, and diabetes mellitus, among others.Many factors may contribute to gallstone formation and the outcome of the disease and surgery.Therefore, the study recommends that health workers offer tailored education, especially targeting the highlighted factors found in this study, to create awareness of disease control measures in the general population.Also, keep in mind these factors when dealing with patients who complain of abdominal pain.The study also recommends future research be conducted evaluating the feeding of the affected group in order to establish the significant contributing factor to the number of cholelithiasis cases reported.