Gallbladder disease in patients with primary sclerosing cholangitis☆
Introduction
Primary sclerosing cholangitis (PSC) is an idiopathic chronic cholestatic inflammatory liver disease with a close association to inflammatory bowel disease (IBD) [1]. PSC is characterized by diffuse fibrosing inflammation of the intrahepatic and/or extrahepatic bile ducts, resulting in bile-duct obliteration, biliary cirrhosis, and eventually hepatic failure [2], [3]. The prevalence of gallbladder abnormalities, including gallstones, thickening of the gallbladder wall and malignancy, has previously been reported to be 41% [4]. Complicated gallstone disease can lead to secondary sclerosing cholangitis, with radiological changes similar to PSC [5]. Differentiating between primary and secondary sclerosing cholangitis can be difficult when gallstones are present, especially in cases without concomitant inflammatory bowel disease. However, gallstones seem to be part of the spectrum of PSC and have also been shown to be associated with symptoms such as abdominal pain, pruritus and bacterial cholangitis [6].
Patients with PSC run an increased risk of developing cholangiocarcinoma. The reported prevalence of this complication ranges from 8% to 20% [7], [8], [9], while the risk of gallbladder carcinoma is not known. Buckles et al. recently showed that in PSC patients, gallbladder polyps are malignant in as many as 57% of cases [10], whereas the reported prevalence in patients without PSC is no more than 0.2–20% [11], [12], [13], [14]. Cholecystectomy has therefore been recommended to be considered in all PSC patients in whom a polyp is identified, whereas in patients without PSC it is safe to keep polyps smaller than 10 mm under observation. However, surveillance of the gallbladder for identification of polyps in PSC is still controversial.
The aim of the present study was to assess the occurrence of gallbladder abnormalities, including gallstones, cholecystitis and gallbladder mass, in a large cohort of PSC patients. We also wanted to study the impact of gallbladder abnormalities on the prognosis of PSC.
Section snippets
Definitions
The diagnosis of PSC was based on typical cholangiographic findings in combination with clinical, biochemical, and histological data [15], [16], [17]. Secondary causes of sclerosing cholangitis were excluded before establishing the diagnosis of PSC. The cholangiographic methods used were either endoscopic retrograde cholangiography (ERC; n = 185), magnetic resonance cholangiography (MRC; n = 96), percutaneous transhepatic cholangiography (n = 4) or peroperative cholangiography (n = 1). The diagnosis of
General features
The clinical characteristics of the 286 patients included in the study are shown in detail in Table 1. Of the patients with IBD, 10% had Crohn’s colitis. None of these patients had substantial ileal involvement. Liver biopsies were available in 215 (75%) patients. Among these patients, 16 (6%) had stage I, 63 (22%) stage II and 62 (22%) stage III fibrosis, while 73 (26%) had stage IV (cirrhosis). Twenty-six patients had either colon carcinoma (n = 9) or high-grade colonic dysplasia (n = 17). Nine
Discussion
The present study indicates that gallbladder abnormalities are common in patients with PSC, with a frequency of 41%. One in four of all the PSC patients had gallstones. This is higher than in the general Swedish population, where the prevalence of gallstones in 40-year-old men and women is reported to be 4% and 11%, respectively [24]. Although gallstones are generally more common in females, in the present study the increased frequency in connection with PSC applied to both sexes, with rates of
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The authors declare that they do not have anything to disclose regarding funding from industries or conflict of interest with respect to this manuscript.