|Year : 2022 | Volume
| Issue : 1 | Page : 17-19
A study on association of iron deficiency and gall stones in cholelithiasis patients
Stephen K Punnoose, Sakaran Nair Kailasanadhan
Department of General Surgery, Government Medical College, Kottayam, Kerala, India
|Date of Submission||29-Apr-2022|
|Date of Decision||02-May-2022|
|Date of Acceptance||07-May-2022|
|Date of Web Publication||14-Jul-2022|
Dr. Sakaran Nair Kailasanadhan
Department of General Surgery, Government Medical College, Kottayam, Kerala
Source of Support: None, Conflict of Interest: None
Background: Iron has been shown to have a significant association with gall stones as iron deficiency causes stasis of gall bladder due to the low production of nitric oxide. Reduction of risk factors can prove to go a long way including reducing surgeries for gall stones and associated disorders including pancreatitis, which is associated with morbidity for the patient. Aim: The aim of the study was to find the association between iron deficiency and gall stone disease. Materials and Methods: This was a case–control study in which the patients who underwent ultrasound abdomen in the general surgery department were divided into two groups, one with gallbladder stones (103) and second without gallbladder stones (52) subjects. They were subjected to serum ferritin and serum iron level estimation. The biochemical parameter used as principle maker was iron, and then ferritin was also analysed. Data were compiled into MS excel and was analysed with SPSS. Results: 36.9% of cases had Iron less than the normal value compared to 7.7% of controls with significant P value. Among the subjects with low iron, 90.5% of the subjects had gall stone disease compared to subjects with normal serum iron value with significant P value. Conclusion: We found a significant association between iron deficiency and development of gallbladder stones. Accordingly, correction of iron may help in the curbing of gall stone disease as it is found to be a factor associated with gall stone disease.
Keywords: Association, gall stone, serum ferritin, serum iron
|How to cite this article:|
Punnoose SK, Kailasanadhan SN. A study on association of iron deficiency and gall stones in cholelithiasis patients. Kerala Surg J 2022;28:17-9
| Introduction|| |
Gallstone disease is one of the most common problems affecting the gastrointestinal tract. Autopsy reports have shown a prevalence of gallstones from 11% to 36%. The prevalence of gallstones is related to many factors, which include age, gender and ethnic backgrounds. There are certain conditions which predispose to the development of gallstones of which obesity, pregnancy, dietary factors, Crohn's disease, terminal ileal resection, gastric surgery, hereditary spherocytosis, sickle cell disease and thalassemia are all associated with an increased risk of developing cholelithiasis. Women are three times more likely to develop cholelithiasis than men, and first-degree relatives of patients with gallstones have a two-fold greater prevalence. In this study, one of the risk factors, iron deficiency has been evaluated for association with gallstone disease.
| Materials and Methods|| |
It was a case–control study for 12 months in the department of general surgery of a tertiary hospital from February 2020 to February 2021. The research question was whether iron deficiency is associated with gallstone disease. Patients who underwent ultrasonography (USG) abdomen and were diagnosed to have cholelithiasis were included as cases. The sample size was calculated based on the study by Prasad et al., with the prevalence of 48. So according to the formula
N = Z2 PQ/d2
1.96 × 1.96 × pq/d2
P = 48
Q = 52
d = 20% of P = 20/100 × 48
So, [1.96 × 1.96] × 48 × 52/[9.6 × 9.6] = 104
The sample size was calculated as 104 cases and 52 controls.
Patients who underwent ultrasound abdomen in the department were divided into two groups, those with and without gallbladder stones. They underwent estimation of serum iron level and serum ferritin along with other biochemical parameters. The data obtained were compiled into MS excel and assessed statistically using software SPSS (IBM-SPSS Software, India). The biochemical parameter used was serum iron as a principal tool and serum ferritin and peripheral smear as other biochemical and pathological parameters.
A pro forma was filled for personal information, history taking and clinical examination. Both symptomatic and incidental gall bladder stone patients were included. Those with inflammatory conditions and those who had already been treated for iron deficiency anaemia, haemolytic anaemia or haemosiderosis were excluded. Quantitative parameters were expressed in mean ± Standard deviation. Statistical analysis was done with appropriate test. The level of significance was a P ≤ 0.05, and high level of significance corresponded to a P ≤ 0.01.
| Results|| |
Majority of the patients in both the groups belonged to the 20–40 years of age group, with the control group also having more in the same age group [Table 1].
Females constituted the majority (93/155, 60%) as against the males (62/155, 40%). The pattern was similarly higher in the females in both the case (63/103, 61.2%) and control (30/52, 57.7%), against the males (40/103, 38.8%) and (22/52, 42.3%).
90/103 cases (87.4%) were symptomatic, whereas none of the control group was symptomatic. Chi-square analysis of the distribution of comorbidities showed that there was significant variation between the two groups in the presence of comorbidities [Table 2].
The serum iron, serum ferritin, serum high-density lipoprotein HDL, and serum triglycerides were statistically significantly higher in the control group. Serum creatinine and serum low-density lipoprotein were significantly higher in the cholelithiasis group [Table 3].
There was no statistically significant difference between the haemoglobin values in the two groups either in the males or females.
The value of serum iron was low in the majority of female patients (95.2%) against the male patients (46.9%) with a statistically significant difference (P = 0.000). Low levels of serum iron were more in the 20–40 years' group (45.2%), and this was statistically significant (P = 0.048). All patients with low serum iron had low Hg level below 13.5 g/dl. 90.5% of the patients with low serum values had gall bladder stones. Contracted or distended gallbladders were more common in the low iron level group. This variation was however not statistically significant.
The ferritin value was lower in the case group (14/103, 13.6%), whereas the value was not low in any of the controls (0/52, 0%) with P = 0.05. The ferritin value was lower in the case group in both males and females, whereas the value was not low in any of the controls in both males and females.
The serum creatinine was not statistically significantly different in the case and control groups. The serum cholesterol level was significantly higher in the case group (43/103, 14.7%) and controls (11/52, 21.2%) with P = 0.003. The serum triglyceride was not statistically significantly different in the case and control groups.
On ultrasonic examination, gall bladder sludge was present in 12/103 (11.7%) in the case group against none in the control group with P = 0.038. 9/103 (8.7%) of the case group showed distension of the gall bladder, whereas none of the control group showed distension. Gall stones were seen more in the age group above 40 years compared to the younger age group, but this difference was not statistically significant.
| Discussion|| |
One hundred and fifty-five subjects were analysed, which were divided into 103 cases and 52 controls. They were cross-matched for different variables.
In 2012, a study conducted by Prasad et al., there were 62% female patients with gallstone disease who had serum iron levels below the normal value. There were 38% females in the healthy volunteer group whose serum iron levels were below normal. There were only 12% female patients with gallstones whose serum iron levels were normal, which was 38% females in the healthy control group.
In 2014, Misra et al. conducted a prospective study; all the 100 patients of cholelithiasis were divided into groups A and B based on serum iron levels. The 88 patients fell in group A and 12 patients in group B. The serum iron content of group B patients was found to be significantly lower than group a patient (P < 0.005). In this study, 36.9% of cases had iron less than the normal value when compared to the control which showed an iron deficiency in 7.7% of the subjects. This result is significant when the P values is analysed (P = 0.000).
Furthermore, among the subjects with low iron, 90.5% of the subjects had gall stone disease when compared to the subjects with normal serum iron value. This result was significant since the P value is in the significant range.
In a study conducted by Johnston et al., this was a prospective study conducted over a period of 24 months, 50 patients suffering from cholelithiasis confirmed by USG were included in this study. Fifty healthy volunteers were taken as the control group. 74% of patients with gallstones had normal value of serum ferritin; in this 48% were anaemic whereas 68% in the control group had normal value and only 2% were anaemic. In patients with gallstones, most were anaemic, whereas in the control group most of them were non-anaemic.
When analysing the male patients, in the group containing cases, 72.8% of the subjects were anaemic when compared to controls which showed 67.3% with anaemia. On analysis of the female patients, in the group containing cases, 48.5% of the subjects were anaemic and 42.3% of control group were anaemic. On analysis of P value for both the groups, it was found to be insignificant.
In a study by Arora and Yadav, in males, serum ferritin was low in 64.5% of cases and 16.66% of controls. Serum ferritin levels were normal in 35.50% of cases and 66.66% of controls. Serum ferritin was above normal in 16.66% of control. Among females, serum ferritin was low in 35.5% of cases and 15.38% of controls. Serum ferritin was normal in 64.50% of cases and 61.53% of controls. Serum ferritin was above normal in 23.07% of control. In this study, when males were 13.6% of cases had a low ferritin when compared to the control group which had no subjects with a low ferritin value. This result was found to be significant when the P value was analysed. When the females were analysed, 13.6% of cases had low ferritin when compared to the controls which showed none of the subjects with low ferritin which was also significant when the P value was analysed. In this study, the age distribution of these patients in group A having gall stone showed 3% in the age group of 15–19 years, 15.5% in the age group of 20–29 years, 27.5% in the age group of 30–39 years, 22.5% in 40–49, 19.5% in 50–59, and 12% in 60–70 years. The mean age in case group was 41.78 ± 12.81 and in control group was 40.02 ± 12.94. There was low prevalence of gallstones in young population and highest prevalence of gallstones among 30–39 years. In the present study, gall stone disease was more prevalent in the age group above 40 years.
Serum iron is subjected to various factors including inflammation and other comorbidities like chronic kidney disease hence the estimation is sometimes erratic. Although ferritin is a measure of iron stores in the body, iron deficiency cannot be fully assessed by it alone. It needs other parameters such as transferrin saturation and total iron-binding capacity which are expensive.
| Conclusion|| |
In this study in which a total of 155 subjects were divided into 2 arms as 103 cases and 52 controls respectively, were analysed for different variables with relation of iron and cholelithiasis as the primary objective for analysis. We found a significant association between iron deficiency and development of gallbladder stones with statistically significant P value. The other variable which was analysed to be significant was that the subjects with cholelithiasis were anaemic when compared to those without. The correction of iron may help in the curbing of gall stone disease as it is found to be a factor associated with it. This knowledge can help in the prevention of cholelithiasis and its associated complications which include biliary pancreatitis and cholangitis which can be even life-threatening.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Misra PK, Dalal S, Kumawat M, Kharb S. Role of trace elements in the formation of gall stones. Asian J Biochem 2014;9:213-20.
Johnston SM, Murray KP, Martin SA, Fox-Talbot K, Lipsett PA, Lillemoe KD, et al.
Iron deficiency enhances cholesterol gallstone formation. Surgery 1997;122:354-61.
Arora BK, Yadav AK. Serum iron and serum ferritin levels in cholelithiasis: A randomized study. Int Surg J 2018;5:1411-6.
[Table 1], [Table 2], [Table 3]