|Year : 2018 | Volume
| Issue : 6 | Page : 1375-1378
Incidence of nonalcoholic fatty liver disease in patients undergoing laparoscopic cholecystectomy
Ranendra Hajong, Malaya Ranjan Dhal, Narang Naku, Buru Kapa
Department of General Surgery, NEIGRIHMS, Shillong, Meghalaya, India
|Date of Web Publication||30-Nov-2018|
Dr. Ranendra Hajong
NEIGRIHMS, Shillong - 793 018, Meghalaya
Source of Support: None, Conflict of Interest: None
Introduction: Nonalcoholic fatty liver disease (NAFLD) includes a host of disease spectrum ranging from simple steatosis to steatohepatitis, cirrhosis liver, and even hepatocellular carcinoma. NAFLD can occur at all ages, and the highest prevalence is found in the age group of 35–55 years. NAFLD is becoming the commonest cause leading to hepatic cirrhosis, but there is no prescribed therapy for this common condition. Reduction in body weight may reverse the condition. Aim: To find the prevalence of NAFLD in a cohort of patients undergoing laparoscopic cholecystectomy in this part of the country and also to evaluate the usefulness of routine liver biopsy for the diagnosis of NAFLD. Materials and Methods: Interventional type of cross-sectional study. In all, 200 consecutive patients underwent a liver biopsy at the end of a standard laparoscopic cholecystectomy, and detailed histopathological examination was done. Clinical, biochemical, demographic, and anthropometric variables were obtained prospectively. NAFLD Activity Score (NAS) was obtained for each patient. Statistical analysis was done using SPSS version 22. Results: A total of 200 patients (140 females and 60 males) were included in the study. In all, 138 patients were categorized as non-nonalcoholic steatohepatitis (NASH), 39 patients as borderline/suspicious NASH, and 23 patients had definitive NASH. A higher body mass index, weight, total cholesterol, low-density lipoprotein, alkaline phosphatise, and weight circumference were found in patients with NASH. Conclusion: The high prevalence of NAFLD in patients with gallstone disease may justify routine liver biopsy during cholecystectomy to establish the diagnosis, stage, and possibly direct therapy.
Keywords: Gallstone disease, liver biopsy, obesity, steatohepatitis
|How to cite this article:|
Hajong R, Dhal MR, Naku N, Kapa B. Incidence of nonalcoholic fatty liver disease in patients undergoing laparoscopic cholecystectomy. J Family Med Prim Care 2018;7:1375-8
|How to cite this URL:|
Hajong R, Dhal MR, Naku N, Kapa B. Incidence of nonalcoholic fatty liver disease in patients undergoing laparoscopic cholecystectomy. J Family Med Prim Care [serial online] 2018 [cited 2019 Apr 25];7:1375-8. Available from: http://www.jfmpc.com/text.asp?2018/7/6/1375/246476
| Introduction|| |
Nonalcoholic fatty liver disease (NAFLD) is emerging as the most common liver abnormality affecting 2.8%–24% of the general population worldwide. NAFLD ranges from fatty liver to steatohepatitis without significant liver damage to hepatocellular inflammation and damage with or without significant fibrosis and cirrhosis in the absence of significant alcohol intake.,, NAFLD usually occurs in two phases. Initially, triglycerides are deposited in the hepatocytes without causing any damage to the liver. But later on due to lipid peroxidation and oxidative stress, hepatic damage takes place., Patients with gallstones are found to have associated NAFLD as both the disease conditions share similar risk factors such as obesity, diabetes mellitus, and hypertriglyceridemia.
| Materials and Methods|| |
The study was conducted from September 2015 to August 2017. Consenting patients above 18 years of age with no history of alcohol intake for the past 6 months and seronegative for hepatitis B and C were included in the study.
Keeping the prevalence at 32% by Mohan et al. in South India and by Majumdar et al. at 30.7% in Northern India in community-based studies; the absolute precision was kept at 10%, and the sample size was determined to be 87. By keeping a design effect of two, the sample size was calculated at 174. The final sample size was calculated at 200 keeping the refusal rate at 15%.
Patients with clinical or biochemical evidence of hepatitis due to autoimmune, viral hepatitis, genetic, cholestatic, or drug-induced etiology and also patients with history of alcohol intake of ≥20 g/day were excluded from the study.
At the end of standard laparoscopic cholecystectomy, liver tissue of approximately 1.5 cm in diameter was taken with endo scissor and sent for histopathological examination. The tissues were examined under hematoxylin–eosin stain for morphological features of ballooning, steatosis, and lobular inflammation; and Masson's trichrome stain was used for fibrosis staging.
Each biopsy specimen was evaluated by NAFLD Activity Score (NAS) proposed by the NASH Clinical Research Network (CRN). Based on the NAS-CRN, the biopsies were categorised as non-nonalcoholic steatohepatitis (NASH), borderline/suspicious NASH, and definitive NASH. Steatosis was graded as Grade I: >5%–33%, Grade II: >33%–66%, and Grade III: >66%.,
NAS score ranges from 0 to 8 after taking into account the unweighted sum of scores of steatosis (0–3) ballooning (0–2), and lobular inflammation (0–3). A value of NAS <3 was categorised as non-NASH, 3–4 as suspicious/borderline NASH, and >5 as NASH.
Fibrosis was staged on a scale of 0–4 as follows:
- Stage 0: absence of fibrosis
- Stage 1: perisinusoidal or portal fibrosis (1a: mild/delicate zone 3 fibrosis, 1b: moderate/dense zone 3 fibrosis, 1c: portal fibrosis only)
- Stage 2: peri-sinusoidal and portal/periportal fibrosis
- Stage 3: septal or bridging fibrosis
- Stage 4: cirrhosis
Means with standard deviation of various variables were calculated and their means were compared using independent samples t-test.
| Results|| |
A total of 200 patients (140 females and 60 males) were included in the study. In all, 138 patients were categorized as non-NASH, 39 patients as borderline/suspicious NASH, and 23 patients had definitive NASH. The mean age in patients with NASH was 39.47 ± 11.701 years, and in non-NASH group the mean age was 38.64 ± 12.124 years.
The other parameters between the two groups are shown in the [Table 1]. There was no difference in the levels of blood sugar, serum bilirubin, aspartate aminiotransferase, alanine aminotransferase (ALT), high-density lipoprotein, and height of the patients in both the groups. Body mass index (BMI) in patients with NASH was significantly higher (26.691 ± 2.155) than non-NASH patients (22.861 ± 1.900) with a P value < 0.001. The mean weight was also significantly higher (66.00 ± 8. 343 KG) in NASH than non-NASH group of patients (55.22 ± 5.679) with a P value <0.001.
|Table 1: Different parameters in nonalcoholic steatohepatitis and non–nonalcoholic steatohepatitis group of patients|
Click here to view
Total cholesterol was also found to be higher in the NASH (176.63 ± 8.286 mg/dL) than those in non-NASH group of patients (168.83 ± 10.759) which was statistically significant (P < 0.001). Serum low-density lipoproteins were also significantly higher in NASH (90.58 ± 7.858) than in non-NASH group of patients (85.72 ± 7.742) with a P value <0.001.
Patients in NASH group had higher waist circumference (82.11 ± 5.261 cms) than non-NASH group of patients (73.38 ± 3.878) which is statistically significant (P < 0.001). Among the biochemical parameters, only serum alkaline phosphatase was found to be significantly increased in NASH (68.69 ± 7.933) group of patients.
| Discussion|| |
In this study, the prevalence of patients with NAFLD was 31% which was similar to the findings of Mohan et al. (32%) in urban South Indian population and Anindo Majumdar et al. (30.7%) in rural North Indian population. Singh et al. and Bajaj et al. in their hospital-based studies found prevalence of NAFLD to be 24.5% and 32.2%, respectively, similar to this study. Similar prevalence was seen outside India also. Dassanayake et al. found a prevalence of 32.6% in middle-aged population in neighbouring Sri Lanka similar to this study. The prevalence ranged from 23.4% to 46% in some other studies.,,,, Whereas Farah A et al. in the neighbouring Pakistan found a very high prevalence of 62.5%.
Lobular inflammation and ballooning along with steatosis are the main features required to diagnose NASH. Liver biopsy is the gold standard to assess and diagnose these histopathological characteristics and also to predict the prognosis.,,
High BMI was seen in patients with NASH similar to the studies of Farah A et al. Higher waist circumference was found among patients with NASH in this study similar to many previous studies.,,,,
A high serum cholesterol level was also found in this study similar to other studies., A high ALT level correlates well with high steatosis and high activity as shown by Rastogi et al., but it was found to be similar in both groups of patients in this study.
Awareness of this entity among the rural surgeons might enable them to undertake studies by ultrasonography while scanning the abdomen for other pathologies and also to check the liver for any fatty changes either grossly or by biopsy followed by histopathological examination of the biopsies, so that proper dietary advice and exercises may be advised to the patients to prevent further progress of their fatty liver conditions.
| Conclusion|| |
Patients with cholelithiasis have a high prevalence of NAFLD, which is 31%. Hence, patients at the time of discharge were advised about lifestyle modifications in the form of regular exercises, diet modifications to ingest balanced diets as advised by the Institute's dieticians, to take seasonal fruits regularly, and so on. Patients were also warned about the possible progress of their liver conditions to cirrhosis and even hepatocellular carcinoma if they do not take proper care of their health.
Limitations of the study
The study population was patients with gallstones who share similar risk factors to develop NAFLD. Therefore, the results may not be representative of the general population of the region. Hence, population-based prospective studies may be undertaken to get the actual incidence of NAFLD in the general population.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Clark JM, Brancati FL, Diehl AM. The prevalence and etiology of elevated aminotransferase levels in the United States. Am J Gastroenterol 2003;98:960-7.
Angulo P, Kleiner DE, Dam-Larsen S, Adams LA, Bjornsson ES, Charatcharoenwitthaya P, et al.
Liver fibrosis, but no other histologic features, is associated with long-term outcomes of patients with nonalcoholic fatty liver disease. Gastroenterology 2015;149:389-97.
Bellentani S, Marino M. Epidemiology and natural history of non-alcoholic fatty liver disease (NAFLD). Ann Hepatol 2009;8 Suppl 1:S4-8.
Bedossa P. Pathology of non-alcoholic fatty liver disease. Liver Int 2017;37 Suppl 1:85-9.
Browning JD, Horton JD. Molecular mediators of hepatic steatosis and liver injury. J Clin Invest 2004;114:147-52.
Haque M, Sanyal AJ. The metabolic abnormalities associated with non-alcoholic fatty liver disease. Best Pract Res Clin Gastroenterol 2002;16:709-31.
Fracanzani AL, Valenti L, Russello M, Miele L, Bertelli C, Bellia A, et al.
Gallstone disease is associated with more severe liver damage in patients with non-alcoholic fatty liver disease. PLoS One 2012;7:e41183.
Mohan V, Farooq S, Deepa M, Ravikumar R, Pitchumoni CS. Prevalence of non-alcoholic fatty liver disease in urban South Indians in relation to different grades of glucose intolerance and metabolic syndrome. Diabetes Res Clin Pract 2009;84:84-91.
Majumdar A, Misra P, Sharma S, Kant S, Krishnan A, Pandav CS, et al.
Prevalence of nonalcoholic fatty liver disease in an adult population in a rural community of Haryana, India. Indian J Public Health 2016;60:26-33.
] [Full text]
Kleiner DE, Brunt EM, Van Natta M, Behling C, Contos MJ, Cummings OW, et al.
Design and validation of a histological scoring system for nonalcoholic fatty liver disease. Hepatology 2005;41:1313-21.
Neuschwander-Tetri BA, Caldwell SH. Nonalcoholic steatohepatitis: Summary of an AASLD single topic conference. Hepatology 2003;37:1202-19.
Brunt EM, Janney CG, Di Bisceglie AM, Neuschwander-Tetri BA, Bacon BR. Nonalcoholic steatohepatitis: A proposal for grading and staging the histological lesions. Am J Gastroenterol 1999;94:2467-74.
Singh SP, Nayak S, Swain M, Rout N, Mallik RN, Agrawal O, et al.
Prevalence of nonalcoholic fatty liver disease in coastal Eastern India: A preliminary ultrasonographic survey. Trop Gastroenterol 2004;25:76-9.
Bajaj S, Nigam P, Luthra A, Pandey RM, Kondal D, Bhatt SP, et al.
A case-control study on insulin resistance, metabolic co-variates & prediction score in non-alcoholic fatty liver disease. Indian J Med Res 2009;129:285-92.
] [Full text]
Dassanayake AS, Kasturiratne A, Rajindrajith S, Kalubowila U, Chakrawarthi S, De Silva AP, et al.
Prevalence and risk factors for non-alcoholic fatty liver disease among adults in an urban Sri Lankan population. J Gastroenterol Hepatol 2009;24:1284-8.
Kim HJ, Kim HJ, Lee KE, Kim DJ, Kim SK, Ahn CW, et al
. Metabolic significance of non-alcoholic fatty liver disease in nonobese, nondiabetic adults. Arch Int Med 2004;164:2169-75.
Williams CD, Stengel J, Asike MI, Torres DM, Shaw J, Contreras M, et al.
Prevalence of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis among a largely middle-aged population utilizing ultrasound and liver biopsy: A prospective study. Gastroenterology 2011;140:124-31.
Zelber-Sagi S, Nitzan-Kaluski D, Halpern Z, Oren R. Prevalence of primary non-alcoholic fatty liver disease in a population-based study and its association with biochemical and anthropometric measures. Liver Int 2006;26:856-63.
Jimba S, Nakagami T, Takahashi M, Wakamatsu T, Hirota Y, Iwamoto Y, et al.
Prevalence of non-alcoholic fatty liver disease and its association with impaired glucose metabolism in Japanese adults. Diabet Med 2005;22:1141-5.
Selm SA. Prevalence of non-alcoholic fatty liver disease (NAFLD) and its association with metabolic syndrome in adults people living in Aden. Middle East J Fam Med 2010;8:17-20.
Ahmed F, Baloch Q, Memon ZA, Ali I. An observational study on the association of nonalcoholic fatty liver disease and metabolic syndrome with gall stone disease requiring cholecystectomy. Ann Med Surg (Lond) 2017;17:7-13.
Sanyal AJ, Brunt EM, Kleiner DE, Kowdley KV, Chalasani N, Lavine JE, et al.
Endpoints and clinical trial design for nonalcoholic steatohepatitis. Hepatology 2011;54:344-53.
Chalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, Cusi K, et al.
The diagnosis and management of non-alcoholic fatty liver disease: Practice guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology 2012;55:2005-23.
Hübscher SG. Histological assessment of non-alcoholic fatty liver disease. Histopathology 2006;49:450-65.
Rastogi A, Shasthry SM, Agarwal A, Bihari C, Jain P, Jindal A, et al.
Non-alcoholic fatty liver disease – Histological scoring systems: A large cohort single-center, evaluation study. APMIS 2017;125:962-73.