Risk factors for gallstone disease in a hospital-based study.Abstract Background. We investigated the risk factors for gallstone disease gallstone disease Surgery The constellation of Sx associated with gallstones. See Cholecystitis, Gallstone. in Taiwan. Methods. We retrospectively analyzed medical records of patients receiving periodic health examination at China Medical College Hospital from January to December 2000. A detailed history, physical examination, biochemical measurements, and abdominal ultrasonography ultrasonography /ul·tra·so·nog·ra·phy/ (-so-nog´rah-fe) the imaging of deep structures of the body by recording the echoes of pulses of ultrasonic waves directed into the tissues and reflected by tissue planes where there is a change in were done. Results. The 602 men (58.6%) and 426 women (41.4%) had a mean age of 49.2 [+ or -]12.8 years (range, 18 to 87). The prevalence of gallstone disease was 7.8% in women and 6.5% in men. After controlling for other covariates, multivariate logistic regression analysis showed that with a reference group aged less than 40 years as a comparison, both men and women aged 65 or older were more likely to have gallstone disease. Conclusions. Age in both sexes and hepatitis C virus
********** GALLSTONE DISEASE is worldwide, but its prevalence of gallstones Gallstones Definition A gallstone is a solid crystal deposit that forms in the gallbladder, which is a pear-shaped organ that stores bile salts until they are needed to help digest fatty foods. shows regional variation among the world population. (1-18) In Western countries, the reported prevalence of gallstones has been around 15.5% to 18.8% in men and 23.8% to 30.2% in women. (7,18) The prevalence is reported to be around 3.6% in Japan (14) and 4.3% in Taiwan. (9) The majority of cases of gallstones are asymptomatic and undiagnosed. (12) In the report of Brasca et al, (18) 72.2% of patients with gallstones were asymptomatic, and 87% were unaware of this disease. Thus, gallstones are often found incidentally in a periodic health examination or community health survey. (9) Although the real mechanism of biliary calculi Calculi (singular, calculus) Mineral deposits that can form a blockage in the urinary system. Mentioned in: Urinary Incontinence is still elusive, its related factors have been widely assessed. In current reports, sex, age, obesity, glucose intolerance/diabetes mellitus, dyslipidemia, alcohol consumption, number of pregnancies, use of oral contraceptives Oral Contraceptives Definition Oral contraceptives are medicines taken by mouth to help prevent pregnancy. They are also known as the Pill, OCs, or birth control pills. , and menopause are closely associated with gall-stones. (1-9,11-18) There have been few reports about the risk factors for gallstones in Taiwan. (9) From a public health standpoint, more data about the risk factors associated with gallstones would help in establishing preventive strategies. Therefore, the object of this study was to assess the prevalence of gallstone disease and its risk factors. SUBJECTS AND METHODS We conducted a retrospective, exploratory, cross-sectional study cross-sectional study n. See synchronic study. cross-sectional study, n the scientific method for the analysis of data gathered from two or more samples at one point in time. . From January to December 2000, we analyzed the medical records of all patients receiving periodic health examination with scheduled items at the Department of Family Medicine of China Medical College Hospital in Taichung City, Taiwan. No sampling method was required. The 1,028 subjects who were included for further analysis were grossly healthy and in most cases, without obvious serious disease. Data collection including history of systemic diseases, medications, smoking, and alcohol consumption, and complete physical examination were done by the doctors at the department of family medicine. If a subject currently still smoked, the status was defined as smoking. If a subject never smoked or had stopped smoking, the status was defined as no smoking. If a subject had the habit of alcoholic abuse, the status was defined as drinking. If the subject never drank alcohol, had quit drinking, or drank only occasionally, the status was defined as no drin king. Ultrasonography of the abdomen was done by the gastroenterologists using a high resolution real-time machine (Toshiba Sonolayer SSA-270A, convex-type 3.5 MHz (MegaHertZ) One million cycles per second. It is used to measure the transmission speed of electronic devices, including channels, buses and the computer's internal clock. A one-megahertz clock (1 MHz) means some number of bits (16, 32, 64, etc. transducer, Japan). Gallstones were diagnosed according to the international criteria. (9,18) Subjects with gallstone disease were defined as those who had gallstones at examination or who had previously had cholecystectomy Cholecystectomy Definition A cholecystectomy is the surgical removal of the gallbladder. The two basic types of this procedure are open cholecystectomy and the laparoscopic approach. for gallstones. Blood pressure was measured using a mercury sphygmomanometer sphygmomanometer /sphyg·mo·ma·nom·e·ter/ (sfig?mo-mah-nom´e-ter) an instrument for measuring arterial blood pressure. sphyg·mo·ma·nom·e·ter or sphyg·mom·e·ter n. with the patient in the sitting position. Weight and height were measured. Venous blood venous blood n. Abbr. v Blood that has passed through the capillaries of various tissues other than the lungs, is found in the veins, in the right chambers of the heart, and in pulmonary arteries, and is usually dark red as a result of a samples were obtained in the morning after a 12-hour overnight fast. A number of biochemical markers, such as total cholesterol, triglyceride, high-density lipoprotein high-density lipoprotein n. Abbr. HDL A lipoprotein that contains relatively small amounts of cholesterol and triglycerides and is associated with a decreased risk of atherosclerosis and coronary artery disease. (HDL (Hardware Description Language) A language used to describe the functions of an electronic circuit for documentation, simulation or logic synthesis (or all three). Although many proprietary HDLs have been developed, Verilog and VHDL are the major standards. ) cholesterol, fasting glucose fasting glucose Fasting blood sugar, fasting plasma glucose Endocrinology Glucose obtained from a Pt who has had nothing–except water by mouth for 8+ hrs; FG is used in evaluating Pts for possible DM Ref range 65-115 mg/dL non-diabetic; 110-140 mg/dL, , uric acid uric acid (y  r`ĭk), white, odorless, tasteless crystalline substance formed as a result of purine degradation in man, other primates, dalmatians, birds, snakes, and lizards. , aspartate aminotransferase aspartate aminotransferasen. Abbr. AST See SGOT. aspartate aminotransferase an enzyme that catalyzes the reversible transfer of an amino group: $$\eqalign $$ (AST (AST Computer, Irvine, CA) A PC manufacturer founded in 1980 by Albert Wong, Safi Quershey and Tom Yuen (A, S and T). It offered a complete line of PCs that sold through its dealer channel. ), alanine alanine (ăl`ənēn'), organic compound, one of the 20 amino acids commonly found in animal proteins. Only the l-stereoisomer participates in the biosynthesis of proteins (see stereochemistry). aminotransaminase (ALT), alkaline phosphatase alkaline phosphatase /al·ka·line phos·pha·tase/ (ALP) (fos´fah-tas) an enzyme that catalyzes the cleavage of orthophosphate from orthophosphoric monoesters under alkaline conditions. , and [gamma]-glutamyl transpep-tidase (GGT GGT ?-glutamyl transferase. GGT Gammaglutamyltransferase, see there ) were analyzed by a biochemical autoanalyser (Hitachi-15) at the Department of Clinical Laboratory of China Medical College Hospital within 4 hours of sample collection. Hepatitis B surface antigen hepatitis B surface antigen n. Abbr. HBsAg An antigen derived from the surface of the hepatitis B virus that is present in the blood in active hepatitis B infection. Also called Australia antigen. was detected by ELISA ELISA (e-li´sah) Enzyme-Linked Immuno-Sorbent Assay; any enzyme immunoassay using an enzyme-labeled immunoreactant and an immunosorbent. ELISA n. (Enzygnost, Dade Behring Marburg GmbH, Germany). Antibody to hepatitis C virus was detected by enzyme immunoassay Immunoassay An assay that quantifies antigen or antibody by immunochemical means. The antigen can be a relatively simple substance such as a drug, or a complex one such as a protein or a virus. test (Abbott HCV HCV abbr. hepatitis C virus HCV 1 Hepatitis C virus, see there 2. Human coronavirus. See Coronavirus. EIA (Electronic Industries Alliance, Arlington, VA, www.eia.org) A membership organization founded in 1924 as the Radio Manufacturing Association. It sets standards for consumer products and electronic components. , third generation). Body mass index (BMI BMI body mass index. BMI abbr. body mass index Body mass index (BMI) A measurement that has replaced weight as the preferred determinant of obesity. ) was measured as weight in kilograms divided by the square of the height in meters. Obesity was defined as a BMI[greater than or equal to]28 and nonobesity as a BMI [greater than or equal to]28. (19) Hypercholesterolemia Hypercholesterolemia Definition Hypercholesterolemia refers to levels of cholesterol in the blood that are higher than normal. Description Cholesterol circulates in the blood stream. It is an essential molecule for the human body. was defined as total cholesterol level 200 mg/dL or hyperlipdemic history. (20,21) Hypertriglyceridemia was defined as a triglyceride level[greater than or eqaul to]200 mg/dL or a history of hyperlipdemia. (20,21) An HDL level <35 mg/dL was considered low. (20,21) Hyperglycemia hyperglycemia: see diabetes. was defined as fasting blood glucose blood glucose Diabetology The principal sugar produced by the body from food–especially carbohydrates, but also from proteins and fats; glucose is the body's major source of energy, is transported to cells via the circulation and used by cells in the presence value 110 mg/dL or a diabetic history. (22) Subjects were considered to have hypertension if the average of blood pressure readings from both arms exceeded 140 mm Hg systolic Systolic The phase of blood circulation in which the heart's pumping chambers (ventricles) are actively pumping blood. The ventricles are squeezing (contracting) forcefully, and the pressure against the walls of the arteries is at its highest. and/or 90 mm Hg diastolic Diastolic The phase of blood circulation in which the heart's pumping chambers (ventricles) are being filled with blood. During this phase, the ventricles are at their most relaxed, and the pressure against the walls of the arteries is at its lowest. or if subjects had a history of hypertension. (23) Hyperuricemia hyperuricemia /hy·per·uri·ce·mia/ (-u?ri-se´me-ah) uricemia; an excess of uric acid in the blood.hyperurice´mic hy·per·u·ri·ce·mi·a n. An unusually high concentration of uric acid in the blood. was defined as serum uric acid level 7 mg/dL in men and 6.5 mg/dL in women. (24) In this hospital, levels of AST >34, ALT >40, GGT >50, and alkaline phosphatase >126 were classified as elevated. Statistical analysis was done with an SAS (1) (SAS Institute Inc., Cary, NC, www.sas.com) A software company that specializes in data warehousing and decision support software based on the SAS System. Founded in 1976, SAS is one of the world's largest privately held software companies. See SAS System. package (Version 6.12, SAS Institute Inc, Cary NC), using the t test, chi-square analysis, and multivariate logistic regressions A P value less than .05 was considered statistically significant. RESULTS Of the 1,028 subjects included, 426 (41.4%) were women and 602 (58.6%) were men. The mean age was 49.2 [+ or -] 12.8 years (range, 18 to 87). The prevalence of gallstone disease in both sexes is shown in the Figure. The prevalence of gallstone disease was 7%, with 5.9% of subjects having gallstones at the time of this study and 1.1% having had previous cholecystectomy for gallstones. The prevalence of gallstones was 7.8% in women and 6.5% in men (P> .05). Table 1 shows the chi-square analysis of gallstone disease. Among women, the significant related factors for gallstone disease were age and hepatitis C virus infection (P < .01). In men, the significant related factor was age (P < .01). Multivariate logistic regression (Table 2) also shows the significant related factors for gallstone disease in women to be older age (odds ratio = 5.6, 95% confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. (CI) = 1.7-18.2, P < .01) and hepatitis C virus infection (odds ratio = 3.6, 95% CI = 1.4-9.7, P < .05). The significant related factor in men was again shown to be age (odds ratio = 8.3, 95% confidence interval = 2.2-30.9, P < .01). DISCUSSION The prevalence of gallstone disease was 7% in our study, which again supported the concept that gallstone disease was more commonly found in the Western world and less in Eastern countries. (7,9,14,18,28) However, it is possible that subjects in our study were more concerned about their health or were having symptoms that prompted them to seek treatment and thus enter this study. If so, the true prevalence of gallstone disease might not be reflected. Furthermore, the prevalence might actually have been overestimated in our study, thus accounting for ours being higher than rates previously reported in Asia. (9,14,28) In our study, with a reference group aged less than 40 years old for a comparison, both men and women aged 65 or older were more likely to reveal gallstone disease. Consistent with previous reports, the prevalence of gallstone disease increased with age in both sexes. (9,11,12,18) Thus, evaluation for possible gallstone disease should be part of the periodic health examination in the elderly. The prevalence of anti-HCV antibody was around 2.5% in community-based studies in Taiwan. (26,27) Some cases of liver cirrhosis liver cirrhosis (sirō´sis), n a degenerative disease of the liver in which hepatic tissue is replaced with connective tissue, commonly a result of chronic alcoholism. See jaundice. are HCV-related in Taiwan. (28) On the other hand, liver cirrhosis is also a risk factor for gallstones. (15) In our study, only 3 subjects with anti-HCV antibody showed liver cirrhosis (2 men and 1 woman). Undoubtedly, hepatitis C virus infection should be an independent risk factor in gallstone disease rather than through the effect of liver cirrhosis. Under the inherent limitation of a cross-sectional study, we could not provide any cause-and-effect implication between hepatitis C virus infection and gallstone disease. Because it is not mentioned in the literature, we could not make any expanded explanation why hepatitis C virus infection was related to gallstone disease only in women. However, we believe our findings are an important addition to the literature, especially considering in the unique population of Taiwan. This study had several limitations. The first is a bias of sampling population. A hospital-based study could not be extrapolated to the general population and the small sample made it unlikely that the subjects are really representative of the Taiwanese general population. However, we expect this study can provide background data for further studies on the epidemiology of gallstone disease in Taiwan so that strategies for prevention can be achieved earlier. The second limitation is inadequate variables. In this study, some factors related to gallstone disease, such as number of pregnancies, use of oral contraceptives, or menopause, (8,11,12,18) were not addressed in detail. Future research might determine whether these factors affect the results of our study. We conclude that advanced age in both sexes and hepatitis C virus infection in women are risk factors for gallstone disease. We also expect this study can establish background information on the epidemiology of gallstone disease, thus allowing development of preventive strategies.
Prevalence of gallstone disease in men and women.
total women men
gallstone 5.9% 6.6% 5.5%
cholecystectomy 1.1% 1.2% 1%
normal 93% 92.2% 93.5%
Note: Table made from pie chart
TABLE 1
Correlates of Gallstone Disease (GD) in Both Sexes by Chi-Square
Analysis
Women
Normal GD
Variable No. (%) No. (%) P Value
Age (years)
< 40 94 (95.9) 4 (4.1) .001
40 to 65 249 (94.3) 15 (5.7)
[greater than or equal to]65 50 (78.1) 14 (21.9)
BMI [greater than or equal to]28
kg/[m.sup.2]
No 346 (92.8) 27 (7.2) .444
Yes 47 (88.7) 6 (11.3)
Fasting glucose [greater than or
equal to]110 mg/dL
No 317 (92.7) 25 (7.3) .651
Yes 76 (90.5) 8 (9.5)
Total cholesterol [greater than or
equal to]200 mg/dL
No 220 (94.0) 14 (6.0) .186
Yes 173 (90.1) 19 (9.9)
Triglyceride [greater than or equal
to]200 mg/dL
No 363 (92.6) 29 (7.4) .562
Yes 30 (88.2) 4 (11.8)
HDL < 35 mg/dL
No 382 (92.7) 30 (7.3) .150
Yes 11 (78.6) 3 (21.4)
Uric acid (men [greater than or
equal to]7, women [greater than or
equal to]6.5 mg/dL
NO 321 (92.8) 25 (7.2) .545
Yes 72 (90) 8 (10)
HBsAg
Negative 346 (92.8) 27 (7.2) .444
Positive 47 (88.7) 6 (11.3)
HCV Ab
Negative 370 (93.4) 26 (6.6) .003
Positive 23 (76.7) 7 (23.3)
Aspartate aminotransferase >34 IU/L
No 341 (93.4) 24 (6.6) .051
Yes 52 (85.3) 9 (14.7)
Alanine aminotransferase >40 IU/L
No 349 (92.8) 27 (7.2) .36
Yes 44 (88) 6 (12)
Alkaline phosphatase >126 IU/L
No 387 (92.4) 32 (7.6) 1.000
Yes 6 (85.7) 1 (14.3)
GGT >50 IU/L *
No 368 (92.5) 30 (7.5) .764
Yes 24 (88.9) 3 (11.1)
Smoking
No 372 (92.1) 32 (7.9) .867
Yes 21 (95.5) 1 (4.5)
Drinking
No 385 (92.1) 33 (7.9) .873
Yes 8 (100) 0 (0)
Fatty liver
No 283 (91.9) 25 (8.1) .795
Yes 110 (93.2) 8 (6.8)
Men
Normal GD
Variable No. (%) No. (%) P Value
Age (years)
< 40 136 (97.8) 3 (2.2) .001
40 to 65 367 (93.6) 25 (6.4)
[greater than or equal to]65 60 (84.5) 11 (15.5)
BMI [greater than or equal to]28
kg/[m.sup.2]
No 488 (93.7) 33 (6.3) .902
Yes 75 (92.6) 6 (7.4)
Fasting glucose [greater than or
equal to]110 mg/dL
No 472 (93.3) 34 (6.7) .745
Yes 91 (94.8) 5 (5.2)
Total cholesterol [greater than or
equal to]200 mg/dL
No 281 (93.7) 19 (6.3) 1.000
Yes 282 (93.4) 20 (6.6)
Triglyceride [greater than or equal
to]200 mg/dL
No 489 (93.1) 36 (6.9) .461
Yes 74 (96.1) 3 (3.9)
HDL < 35 mg/dL
No 508 (92.9) 39 (7.1) .078
Yes 55 (100) 0 (0)
Uric acid (men [greater than or
equal to]7, women [greater than or
equal to]6.5 mg/dL
NO 331 (93.2) 24 (6.8) .866
Yes 232 (93.9) 15 (6.1)
HBsAg
Negative 477 (93.4) 34 (6.6) .855
Positive 86 (94.5) 5 (5.5)
HCV Ab
Negative 539 (93.6) 37 (6.4) 1.000
Positive 24 (92.3) 2 (7.7)
Aspartate aminotransferase >34 IU/L
No 444 (93.5) 31 (6.5) 1.000
Yes 119 (93.7) 8 (6.3)
Alanine aminotransferase >40 IU/L
No 439 (93.8) 29 (6.2) .744
Yes 124 (92.5) 10 (7.5)
Alkaline phosphatase >126 IU/L
No 555 (93.6) 38 (6.4) 1.000
Yes 8 (88.9) 1 (11.1)
GGT >50 IU/L *
No 489 (94.2) 30 (5.8) .134
Yes 74 (89.2) 9 (10.8)
Smoking
No 330 (94.3) 20 (5.7) .465
Yes 233 (92.5) 19 (7.5)
Drinking
No 462 (94.1) 29 (5.9) .324
Yes 101 (91) 10 (9.0)
Fatty liver
No 308 (91.9) 27 (8.1) .110
Yes 255 (95.5) 12 (4.5)
GGT values were missing for 1 woman.
BMI = Body mass index, HDL = high-density lipoprotein cholesterol, HBsAg
= hepatitis B surface antigen, HCVAb = hepatitis C virus antibody, CGT =
[gamma]-glutamyl transpeptidase.
TABLE 2
Results of Multivariate Logistic Regression Analysis of Cases of
Gallstone Disease
Women Men
Variable OR 95% CI OR
Age (<40 years as reference)
40 to <65 1.3 0.4-3.9 3.1
[greater than or equal to]65 5.6 1.7-18.2 * 8.3
HCV Ab (negative as reference)
Positive 3.6 1.4-9.7 +
Men
Variable 95% CI
Age (<40 years as reference)
40 to <65 0.9-10.4
[greater than or equal to]65 2.2-30.9 *
HCV Ab (negative as reference)
Positive
OR = Odds ratio, CI = confidence interval, HCV Ab = hepatitis C virus
antibody.
* P <.01.
+ P <.05.
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KEY POINTS * Gallstone disease is worldwide. * Most cases of gallstones are asymptomatic and undiag-noised * There are few reports about the risk factors of gallstone disease in Taiwan * Our results show that age in both sexes and hepatitis C virus infection in women are the main factors for this disease. From the Departments of Community Medicine and Emergency Medicine, China Medical College Hospital, Taichung, Taiwan. Reprint requests to Kim-Choy Ng, China Medical College Hospital, Department of Emergency Medicine, No 2, Yuh-Der Rd, Taichung City, 404, Taiwan. |
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