The prevalence and natural history of gallstones in spinal cord injured patients

Prophylactic cholecystectomy in individuals with spinal cord injury: A systematic review

CONTEXT

Spinal cord injury (SCI) is associated with several gastrointestinal disorders, and the prevalence of cholelithiasis is high in this population. Because individuals with SCI may have atypical symptoms and more advanced disease, some treatment centers advocate prophylactic cholecystectomy for patients with SCI and gallstone disease.

OBJECTIVE

To systematically review the existence and quality of studies on prophylactic cholecystectomy in individuals with SCI and cholelithiasis.

METHODS

A systematic search of literature up to July 10, 2022 was conducted in accordance with PRISMA guidelines using the Medline, Cochrane, and Web of Science databases. Keywords used were "cholecystectomy," "gallbladder," "cholelithiasis," "gallstone," and "spinal cord injury."

RESULTS

The search identified 118 articles, of which 4 met the inclusion criteria. All these were retrospective observational studies. Prophylactic cholecystectomy was performed in 4-16.5% of the participants. The causes of cholecystectomy were chronic cholecystitis with biliary colic (44.5-63.5%), acute cholecystitis (4-26%), choledocholithiasis (6-11%) and pancreatitis (2-6%). Operative times, conversion rates, estimated blood loss, severity of complications, morbidity and mortality did not differ significantly between individuals with SCI and neurologically able individuals.

CONCLUSION

No prospective cohort studies comparing prophylactic cholecystectomy with conservative management in individuals with SCI and gallstone disease have been conducted. Therefore, there is no robust evidence to support prophylactic cholecystectomy and further studies are required.

Acute Cholecystitis: An Emerging Complication in Spinal Cord Injury Patients in the United States

Background Spinal cord injury (SCI) is a significant medical condition associated with various secondary complications, including cholelithiasis. Cholelithiasis can cause biliary duct obstruction and result in acute cholecystitis. The development of acute cholecystitis in SCI patients has been well studied in the Taiwanese population, showing an increased risk of acute cholecystitis in patients with SCI. The development of cholecystitis has not been well studied in the United States.

Materials and Methods A retrospective review was performed on 3,939 propensity score-matched patients aged 18 to 85 years who had SCI/surgery from 2000 to 2019. Patients were divided based on the development of postoperative complications, specifically cholecystitis with cholecystectomy.

Results SCI consisted of quadriplegia (42%), paraplegia (53%), unspecified lesion of cervical spinal cord (3%), and thoracic spinal cord (2%). All groups were comparable regarding age, gender, body mass index, smoking status, and Charlson comorbidity Index. The incidence of acute cholecystitis with subsequent cholecystectomy among patients with SCI was 43.0 per 10,000 person-years (95% confidence interval: 41.51–44.49). Median follow-up was 36 months. The development of cholecystitis was comparable among females (54.5%) and males (45.5%), and among African Americans (52.5%) and Caucasians (47.5%).

Conclusion There is an association between SCI and development of acute cholecystitis among U.S. patients. As SCI patients do not present with the classic signs of biliary colic, risk assessment for the development of acute cholecystitis will guide patient management and allow neurosurgeons to weigh the risks and benefits of prophylactic treatment for gallbladder complications.

Influence of severity and level of injury on the occurrence of complications during the subacute and chronic stage of traumatic spinal cord injury: a systematic review

OBJECTIVE

Secondary health conditions (SHCs) are long-term complications that frequently occur due to traumatic spinal cord injury (tSCI) and can negatively affect quality of life in this patient population. This study provides an overview of the associations between the severity and level of injury and the occurrence of SHCs in tSCI.

METHODS

A systematic search was conducted in PubMed and Embase that retrieved 44 studies on the influence of severity and/or level of injury on the occurrence of SHCs in the subacute and chronic phase of tSCI (from 3 months after trauma). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

RESULTS

In the majority of studies, patients with motor-complete tSCI (American Spinal Injury Association [ASIA] Impairment Scale [AIS] grade A or B) had a significantly increased occurrence of SHCs in comparison to patients with motor-incomplete tSCI (AIS grade C or D), such as respiratory and urogenital complications, musculoskeletal disorders, pressure ulcers, and autonomic dysreflexia. In contrast, an increased prevalence of pain was seen in patients with motor-incomplete injuries. In addition, higher rates of pulmonary infections, spasticity, and autonomic dysreflexia were observed in patients with tetraplegia. Patients with paraplegia more commonly suffered from hypertension, venous thromboembolism, and pain.

CONCLUSIONS

This review suggests that patients with a motor-complete tSCI have an increased risk of developing SHCs during the subacute and chronic stage of tSCI in comparison with patients with motor-incomplete tSCI. Future studies should examine whether systematic monitoring during rehabilitation and the subacute and chronic phase in patients with motor-complete tSCI could lead to early detection and potential prevention of SHCs in this population.

Increased Risk of Acute Cholecystitis in Patients With Spinal Cord Injury: A Nationwide Population-Based Cohort Study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the risk of acute cholecystitis (AC) in patients with spinal cord injury (SCI) based on a nationwide sample.

SUMMARY OF BACKGROUND DATA

Prior research evaluating the risk of AC in patients with SCI is limited. Moreover, since most previous studies on the association between AC and SCI used case-series designs, little is known about the relative risk of SCI patients developing AC from a longitudinal follow-up, compared with individuals without SCI.

METHODS

We used the data from Taiwan's National Health Insurance Research Database. The SCI group consisted of 11,523 patients with SCI aged between 20 and 90 years. Propensity score matching procedure was employed to minimize potential confounding effects arising from the imbalance in the baseline characteristics. A total of 23,046 propensity score-matched patients without SCI were enrolled in the non-SCI group. We compared the incidence of AC between these two groups, and assessed the impact of SCI on the risk of developing AC.

RESULTS

In the SCI and non-SCI groups, the respective incidence rates of AC were 36.9 (95% confidence interval [CI], 30.0-44.8) and 25.2 (95% CI, 21.2-29.8) per 10,000 person-years. As compared with the non-SCI group, the hazard ratio for the SCI group of AC was 1.71 (95% CI, 1.22-2.41, P = 0.0018); and the cumulative incidence of AC of the SCI group was higher than that of the non-SCI group (P = 0.0036).

CONCLUSION

This population-based cohort study showed that there was an increased risk of AC in patients with SCI.

LEVEL OF EVIDENCE

3.

Incidence of gallstone disease and complications

PURPOSE OF REVIEW

The purpose of this review was to describe the epidemiology of gallstone disease in the era of ultrasound screening and laparoscopic cholecystectomy.

RECENT FINDINGS

Recent general population cohorts, including ultrasound screenings, have contributed to our understanding of formation and clinical course of gallstone disease. Cohorts of symptomatic gallstone disease have been informative about symptom recurrence and need of treatment. Preventive targets for gallstone formation may include obesity and the associated metabolic changes. The presence of gallstone disease is best described as a continuum from asymptomatic to symptomatic disease, with the latter including both pain attacks and complicated disease. Symptomatic disease causes a persistent high risk of symptom recurrence and need of cholecystectomy. The majority of gallstone carriers will remain asymptomatic and about one in five will develop symptoms. Determinants of disease progression from asymptomatic to symptomatic disease include sex, age, body mass index, and gallstone ultrasound characteristics.

SUMMARY

Because of the absence of effective gallstone formation prevention, targets against the metabolic changes in obesity should be further explored in randomized controlled trials. To optimize patient selection for cholecystectomy, treatment algorithms including identified determinants of symptomatic disease in gallstone carriers should be explored in prospective clinical trials.

Beyond broken spines-what the radiologist needs to know about late complications of spinal cord injury

OBJECTIVE

To describe expected imaging findings to assist the emergency room radiologist with recognising complications and pathology unique to the spinal cord injury (SCI) patient population to ensure rapid and accurate diagnosis.

METHODS

Pictorial review.

RESULTS

We review several imaging findings common to persons with chronic SCI, emphasising imaging in the emergency setting and on CT.

CONCLUSION

SCI patients present a unique diagnostic challenge, as they may present with symptoms that are difficult to localise because of abnormal sensation and autonomic instability. Imaging plays an important role in the emergent setting, rapidly differentiating the most commonly encountered complications from less common, unanticipated complications. Radiologists need to be attuned to both the expected findings and potential complications, which may be unique to SCI patients, to ensure accurate diagnosis and treatment in the emergency setting.

MAIN MESSAGES

• Medical complications after spinal cord injury are common and associated with significant morbidity. • Radiologists should be aware of complications unique to the SCI population to aid diagnosis. • Due to abnormal sensation, SCI patients often present with symptoms that are difficult to localise. • In the ED, imaging helps to rapidly differentiate common complications from less anticipated ones.

Acute abdominal emergencies and spinal cord injury; our experiences: a retrospective clinical study

STUDY DESIGN

Retrospective review of medical notes.

OBJECTIVE

To describe clinical, laboratory and examination findings of acute abdominal emergencies (AAE) in Turkish patients with spinal cord injury (SCI) and to examine diagnosis and management of AAE in early stages.

SETTING

Inpatient rehabilitation unit of tertiary research hospital.

METHODS

The medical records of 237 SCI patients were reviewed. The SCI patients who were recruited in the study had been diagnosed with AAE and treated medically or surgically while they were inpatients at the rehabilitation clinic.

RESULTS

Nine out of 237 SCI patients had been diagnosed with one of the AAE. Three patients were AIS A, three patients were AIS B and three patients were AIS C. The most common AAE was acute cholecystitis; three patients were diagnosed with this. The others were single cases of intra-abdominal hemorrhage, intra-abdominal abscess, tuba-ovarian abscess, subileus, Crohn's disease and cholangitis. Three of the patients were treated with surgery and six were treated medically. The most common symptoms in patients were fever, abdominal pain and abdominal discomfort (four of AAE). Three patients had abdominal tenderness and abdominal distension. The expected findings of AAE, rebound and defense, were positive only in two patients.

CONCLUSION

Gall bladder disease is a common cause of AAE. The classic symptoms and examination findings will usually not facilitate acute abdomen diagnosis in the SCI group, so we should be aware of patients' subjective complaints and when necessary use advanced imaging techniques immediately.

Sonographic evaluation of gallbladder contractility in patients with spinal cord injury

PURPOSE

To determine gallbladder volume with sonography during fasting and in response to a fatty meal in patients with spinal cord injuries (SCIs) and compare the results with those obtained in healthy controls.

METHOD

Forty-three patients with SCI and 40 healthy volunteers without clinical evidence of gallbladder disease underwent sonography before and 30 and 60 minutes after the ingestion of a standard fatty meal. The gallbladder fasting volume, resting volume, and gallbladder contractility were calculated, and the results were compared. Correlation between gallbladder contractility and level of lesion, time since injury, use of oxybutynin, and body mass index (BMI) was also assessed.

RESULTS

The mean ejection fraction was significantly lower in the patients with SCIs (40%) compared with healthy controls (63%) (p < 0.001). Gallbladder mean residual volume 60 minutes after ingestion of the fatty meal was lower in the control group (p < 0.001).

CONCLUSION

Gallbladder contractility is impaired in patients with SCI, which may predispose these patients to gallstone formation. There was no correlation between gallbladder contractility and level of the lesion, time since injury, use of oxybutynin, or BMI.

Abdominal ultrasonography findings in patients with spinal cord injury in Korea

This is a retrospective study of 500 patients with spinal cord injury who underwent abdominal ultrasonography as a routine screening test from 2000 to 2003. We analyzed the results according to the different abdominal organ systems. Among the 500 cases, 226 (45.2%) showed abnormal findings. 98 cases of abnormal findings in the liver included 75 of fatty liver and 13 of mass. The 88 cases of abnormal findings in the bladder included 56 of bladder wall thickening, 14 of cystitis and 10 of urinary stone. The 35 cases of abnormal findings in the kidney included 19 of renal cyst and 6 of pelvic dilatation. The 35 cases with gallbladder abnormalities included 19 with gallstones and 11 with biliary sludge. Excluding the cases with bladder wall thickening, there were still 170 cases with abnormal ultrasonographic findings. Abdominal sonography seems to be a useful tool in detecting hidden intraabdominal pathologies in patients with spinal cord injury.

Effects of gender on neurologic and functional recovery after spinal cord injury

OBJECTIVE

To assess gender differences in neurologic and functional outcome measures in persons with spinal cord injury (SCI).

DESIGN

Case series.

SETTINGS

Model Spinal Cord Injury Systems (MSCIS) throughout the United States.

PARTICIPANTS

People (N=14,433) admitted to an MSCIS within 30 days of injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Improvement in American Spinal Injury Association (ASIA) motor index score, ASIA Impairment Scale, level of injury, and FIM instrument scores after SCI.

RESULTS

When examining subjects grouped by severity of injury, changes in ASIA motor index total scores, from system admission to 1-year anniversary, were significantly greater for women than men with either complete ( P =.035) or incomplete ( P =.031) injuries. Functional comparison of men and women, using the FIM motor subscale, revealed that men had higher FIM motor scores at rehabilitation discharge among those with motor-complete injuries, except for those with C1-4 and C6 neurologic levels. Women with motor-incomplete high tetraplegia (C1-4 levels) had higher discharge FIM motor scores than did similarly afflicted men. There were no significant differences in FIM motor scores among men and women with other levels of motor incomplete SCI.

CONCLUSIONS

Gender differences in SCI were seen in several areas. Women may have more natural neurologic recovery than men; however, for a given level and degree of neurologic injury, men tend to do better functionally than women at time of discharge from rehabilitation. Future prospective study of the effects of estrogen on neurologic recovery and the effects of gender on functional potential are recommended.

Gallstones in spinal cord injury (SCI): a late medical complication?

STUDY DESIGN

Prospective controlled study.

OBJECTIVES

To assess the prevalence of cholelithiasis among chronic spinal spinal cord injured (SCI) male patients of the ACHS (Asociación Chilena de Seguridad). To evaluate statistically the prevalence of cholelithiasis among SCI patients compared to a control group and to the general male Chilean population. To assess the correlation between cholelithiasis in chronic SCI patients and usual risk factors such as age, obesity and diabetes mellitus. To assess the association of cholelithiasis in chronic SCI patients and the duration of the spinal cord injury.

SETTING

Rehabilitation Service at the Hospital del Trabajador, in Santiago, Chile.

METHODS

One hundred SCI patients followed up at the Hospital del Trabajador on a regular basis were included in the study; one group consisted of 76 subjects rated ASIA A or B and the other group consisted of 24 subjects rated ASIA C and D. They were all male, older than 20 years old (average age: 41,9 and 42,6 respectively), and suffered from a spinal cord injury greater than one year of evolution. The control group (CG) consisted of 100 male volunteers, without both SCI and history of biliary disease, aged 40.3 years old in average. All three groups underwent ultrasonographic imaging evaluation of the gallbladder and the biliary tract between 1998 and 2000.

RESULTS

The prevalence of cholelithiasis among the groups was the following: 25% in the SCI patients ASIA A and B (19/76), 25% in the SCI patients ASIA C and D (6/24) and 9% (1/100) in the CG. The statistical analysis showed a value of P=0.0037, thus establishing a significant association between cholelithiasis and SCI, both complete and incomplete. The difference was not statistically significant when correlating the presence of cholelithiasis with the neurological level of the injury--above and below T10 (24,1 and 25%, respectively)--with the duration of the SCI, with age, obesity and diabetes mellitus.

CONCLUSIONS

SCI represents a major risk factor for the development of cholelithiasis, and it should be considered a late, secondary complication of a spinal cord injury.

SPONSORSHIP

The present work is sponsored by the Fundación Científica y Tecnológica of the ACHS, grant No 2899.

Cholecystectomy in patients with previous spinal cord injury

BACKGROUND

The number of people in the United States with spinal cord injury (SCI) is estimated at about 200,000. The prevalence of gallbladder disease in this population is about three times as high as in neurally intact people, but the results of surgical treatment have received little attention.

METHODS

A retrospective, population-based study of patients with SCI who later received cholecystectomy for benign gallbladder disease was performed. National computer data sets of all patients receiving medical care in all Department of Veterans Affairs (DVA) medical centers for fiscal years 1994 to 1998 were used. Computer-based data were augmented with chart-based resources.

RESULTS

During the period of interest, there were 21,849 patients with ICD-9-CM codes for SCI in the DVA computer system, among whom 367 had codes for cholecystectomy. After retrieval and review of data from individual charts, 118 were deemed evaluable. There were 68 who had successful laparoscopic cholecystectomy and 14 who required conversion to open cholecystectomy after laparoscopic efforts failed (conversion rate 14 of 82=17%). There were 36 who received planned open cholecystectomy. Patients under the age of 60 years were more likely to have a laparoscopic approach (P <0.05). Emergency cholecystectomies were more likely to be performed via the open route (P <0.01). The morbidity rate was 8 of 68 (12%) for successful laparoscopic cholecystectomy, 4 of 14 (29%) for failed laparoscopic surgery completed by conventional open technique, and 11 of 36 (31%) for planned open surgery. The mortality rate in the traditional surgery group was 1 of 36 (3%). There were no deaths in the other groups.

CONCLUSIONS

We believe this series is the largest so far reported. The mortality rate of cholecystectomy in SCI patients is comparable to that in neurally intact individuals, but the morbidity rate is high. Contractures, stomas, heterotopic ossification, and other sequelae of SCI do not generally cause technical difficulties with surgery. If complications of cholecystectomy are indeed SCI-related, attention to perioperative SCI care could improve outcomes of cholecystectomy. Future research should continue to explore this important research topic.

Gastric surgery

Most significant research relating to gastric surgery in the past year has centered on surgery for gastroesophageal reflux disease (GERD). Antireflux surgery has become more popular with advanced laparoscopic technology. Two previously accepted surgical principles have been challenged by current studies: the importance of division of the short gastrics and the dictum that partial fundoplication is preferred for patients at risk for dysphagia. Additionally, risk factors for postoperative dysphagia have been identified, allowing for better patient selection and education. Further study on the cause of GERD has shown a positive correlation between pathologic gastroesophageal reflux and those with hiatal hernia or disordered esophageal peristalsis, although cause or effect has not yet been established. Literature relating to bariatric surgery has confirmed the safety and efficacy of the laparoscopic Roux-en-Y gastric bypass, and several papers address the appropriateness of prophylactic cholecystectomy in these patients. The role of laparoscopic surgery for treatment of perforated peptic ulcer disease has now been validated, with subsequent eradication of Helicobacter pylori infection. The relationship of H. pylori infection to acutely bleeding ulcers is less clear. Indications for ulcer surgery are predominantly limited now to perforation and bleeding because of the availability of effective acid-reducing medications and recognition of the role of H. pylori infection.

Spinal cord injury medicine. 2. Medical complications after spinal cord injury: Identification and management

This is a self-directed learning module that reviews medical complications associated with spinal cord injury (SCI). It is part of a chapter on SCI medicine in the Self-Directed Physiatric Educational Program for practitioners and trainees in physical medicine and rehabilitation. This article includes discussion of common medical complications that impact rehabilitation and long-term follow-up for individuals with SCI. Issues addressed include the rehabilitation approach to SCI individuals with pressure ulcers, unilateral lower-extremity swelling (deep venous thrombosis, heterotopic ossification, fractures), along with the pathophysiology, assessment, and treatment of spasticity, autonomic dysreflexia, orthostatic hypotension, and pain.

OVERALL ARTICLE OBJECTIVE

To describe diagnostic and treatment approaches for medical complications common to individuals with SCI.

Gallstones

Gallstones are estimated to affect over 20 million people in the United States. Recent studies have clarified the role of various dietary components in gallstone disease. Also, insulin resistance has been demonstrated to be a risk factor for gallstones. Other research has focused on the pathophysiology of gallstones and on clarifying the underlying mechanisms of previously noted risk factors for gallstones. New techniques for the noninvasive diagnosis of bile duct stones continue to be developed and tested. These techniques include computed tomography and magnetic resonance cholangiography. The impact and appropriateness of laparoscopic cholecystectomy continue to debated, and studies point to both overuse and underuse of this operation in the management of the disease.

Atypical gastrointestinal symptoms are not associated with gallstones in patients with spinal cord injury

OBJECTIVE

To determine if nonspecific gastrointestinal (GI) symptoms justify cholecystectomy in patients with spinal cord injury (SCI).

DESIGN

The frequency of GI symptoms was determined in a sample of patients with SCI in whom the presence or absence of gallstones had been previously determined by screening ultrasonography or a known history of cholecystectomy. The prevalence of various symptoms in patients with and without gallstones was compared.

SETTING

The Spinal Cord Injury Unit of the Veterans Affairs Puget Sound Health Care System, which provides rehabilitation and longitudinal primary care for SCI veterans.

PATIENTS

Two hundred ninety-four patients who had undergone either right upper quadrant ultrasonography or cholecystectomy in the past, and who completed a questionnaire concerning GI symptoms.

MAIN OUTCOME MEASURE

Bivariate logistic regression was used to calculate odds ratios (ORs) to determine the strength of associations between the presence of each symptom and the presence of gallstones.

RESULTS

Pain in the right upper quadrant or epigastrium that occurred after meals or at night was significantly associated with gallstones (OR: 3.5; 95% confidence interval [CI] 1.02-11.73). Abdominal pain in other locations and nonspecific symptoms such as bloating and nausea, were not predictive of the presence of gallstones.

CONCLUSIONS

Nonspecific symptoms in patients with SCI are not associated with gallstones and do not justify cholecystectomy in patients with otherwise asymptomatic gallstones.