The burden of gallstone disease in Europe

Abstract

Gallstones are common and may be associated with recurrent bouts of upper abdominal pain, often with nausea and/or vomiting. The frequency of gallstones increases with age, female gender and obesity. The majority of gallstones are asymptomatic. Despite this, gallstone disease is the most common abdominal condition for which patients are admitted to hospital in developed countries.1 Medical presentations usually result from complications or through routine investigations for abdominal pain. Complications attributable to gallstones include chronic inflammation/infection of the gallbladder (cholecystitis), abscess formation, and biliary obstruction, which can result in jaundice or a severe ascending infection of the bile ducts and acute pancreatitis. Most uncomplicated cases that present to clinicians can be effectively treated by keyhole surgery (laparoscopic cholecystectomy), but patients with more severe disease often require multidisciplinary management, involving radiological, gastroenterological and surgical services. Medical management other than the use of antibiotics to treat infection are infrequently employed due to the poor long-term response rates. Although now uncommon, severe cases can be associated with significant morbidity and mortality, particularly in frail or elderly patients.2 To determine the recent prevalence and incidence rates of gallstones, their complications and surgical treatments in Europe, a MedLine database search from 1989 to 2003 was performed. Cholelithiasis is a common disease in most developed countries and a frequent cause of abdominal surgery. For many years, estimates of the frequency of gallstones have been made from necropsy studies or studies of clinically diagnosed cases of gallstones, which do not represent the true prevalence in the general population. As most gallstones stay asymptomatic during a lifetime, clinically diagnosed cases of gallstones represent less than half of the overall prevalence. Although autopsy studies have many drawbacks, they have shown that the prevalence of gallstone disease increases with age and is higher in women than in men. After standardization for age and sex, these studies also show large differences between countries in Europe (Table 1; according to Acalovschi et al.3). Some authors have shown that autopsy data are comparable to ultrasonographic surveys in the same population when standardized for age and sex.4-6 Necropsy data also enable definition of time trends in gallstone prevalence. In a retrospective study from a large town in Romania, a significant increase was found over a 100-year interval.7 More recently, cross-sectional screening of the whole population for gallstone disease has become possible by the use of real-time ultrasonography, which is a noninvasive technique, and not only allows the evaluation of prevalence, but can also be repeated to give the gallstone incidence. Accurate data for both prevalence and incidence of gallstone disease are not available for every country in Europe; most studies come from Italy and Scandinavia. The median prevalence of gallstone disease in the largest population surveys in Europe ranges from 5.9 to 21.9%,8-20 with the highest rates seen in Norway (21.9%) and former East Germany (19.7%), and the lowest rates in Italy (Chianciano 5.9% and Sirmione 6.9%) (Table 2). Most surveys show that the prevalence of gallstones increases with age.12, 13, 16 Prevalence is also higher in women than in men.12, 13, 15, 16 Prevalences of gallstone disease in men and women according to age are shown in 1, 2. Prevalence of gallstone disease in Europe: men.8-12, 14, 17,19-21 Prevalence of gallstone disease in Europe: women.8-14,16,18,19,21 The few prospective ultrasound surveys in Europe that have assessed gallstone incidence show an incidence < 1/100 persons per year (0.34–0.97% in Italy, 0.93% in Denmark).15, 22-25. Incidence rates also increase with age and are higher in women than in men (southern Italy: 0.32 and 0.48% per year in 30–39-year-old men and women, respectively; 1.66 and 1.86% per year in the 60–69-year-old age group, mean 0.71% in men and 0.91% in women;15 Denmark: 0.06 and 0.28% per year in 30-year-old men and women, respectively; 0.66 and 0.74% per year in the 60-year-old age group).22 Incidences can also be calculated from prevalence data, and these show comparable results.26 Incidence studies have shown that gallstones can also disappear due to dissolution or spontaneous passage in 4.5% of patients over 5 years.22 Incidence rates are also time-dependent; in the Sirmione study, the gallstone incidence rate during 1982–87 was 0.60% per year and during 1987–92 was 0.34% per year, indicating a declining incidence in this town in northern Italy.23 The large majority of gallstones remain asymptomatic during a lifetime. Several ultrasonographic population surveys have shown that severe pain in the right upper quadrant lasting for more than 30 min is the most typical symptom suggesting gall