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Routine Liver Biopsy to Screen for Nonalcoholic Fatty Liver Disease (NAFLD) during Cholecystectomy for Gallstone Disease: Is it Justified?

  • 2008 ssat plenary presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Nonalcoholic fatty liver disease (NAFLD) and gallstone disease (GD) share common risk factors. There are no firm recommendations regarding screening of NAFLD in patients at risk. Our aim was to assess the prevalence of and factors associated with NAFLD in a cohort of patients operated for symptomatic GD and evaluate the usefulness of routine liver biopsy.

Methods

Ninety-five consecutive patients underwent a liver biopsy at the end of a standard laparoscopic cholecystectomy for symptomatic GD. Clinical, biochemical, demographic, and anthropometric variables were obtained prospectively.

Results

Fifty-two patients (55%) had biopsies compatible with NAFLD. These patients were classified according to the system proposed by Brunt et al. as follows: grade I, n = 27 (52%); grade II, n = 15 (29%); grade III, n = 10 (19%). Two grade III patients had zone III focal perisinusoidal fibrosis and three had overt cirrhosis. Only 13% of subjects had a suspected diagnosis of NAFLD preoperatively. In multivariate logistic regression, only obesity was significantly associated with NAFLD. There were no complications or mortality.

Discussion

Fifty-five percent of patients with GD have associated NAFLD. Awareness of this association may result in an earlier diagnosis. The high prevalence of NAFLD in patients with GD may justify routine liver biopsy during cholecystectomy to establish the diagnosis, stage, and possible direct therapy.

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Author information

Authors and Affiliations

  1. Gastroenterology and Gastrointestinal Surgery Department, Veracruz Regional Hospital, Veracruz, México

    Antonio Ramos-De la Medina

  2. Digestive Physiology and Motility Laboratory,Medical–Biological Research Institute, University of Veracruz, Iturbide S/N, Veracruz, CP 91910, Mexico

    José M. Remes-Troche, Federico B. Roesch-Dietlen & Silvia Cid-Juarez

  3. University of Veracruz Medical School, Veracruz, México

    Alfonso G. Pérez-Morales & Silvia Martinez

Authors
  1. Antonio Ramos-De la Medina
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  2. José M. Remes-Troche
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  3. Federico B. Roesch-Dietlen
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  4. Alfonso G. Pérez-Morales
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  5. Silvia Martinez
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  6. Silvia Cid-Juarez
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Corresponding author

Correspondence to Federico B. Roesch-Dietlen.

Additional information

Discussion

Michael G. Sarr, M.D. (Rochester, MN): I have three questions. First, this is in a Mexican population, and so how representative of the rest of the genomic world is it? Second, if you find somebody with fatty liver disease, how are you going to treat them? I don’t know of many effective therapies for NAFLD. And third, can you select out the patients whom you should biopsy? So if they are skinny and they don’t have any other of these risk factors, do you need to biopsy them as well?

Jose M. Remes-Troche, M.D. (Veracruz, Mexico): Thank you for your questions. The first question, I think it is very important to remark that in many liver and gallstones diseases, ethnicity has a key role. There are several studies that have shown that gallstone disease is more prevalent in some Latin American countries and in some populations like Hispanics and Native American Indians. Thus, our study is just representative of our population. We believe that further studies regarding ethnicity and genomic issues are required, trying to look for which genes could be related to predicting and try to see if this is the same phenomenon in other populations.

Regarding the second question, one of the main problems that actually we have as a physician is the lack of a gold standard treatment for NAFLD. However, several recent studies have shown that in NAFLD, morbidity and mortality related to liver disease, but mainly to coronary artery disease, is considerably higher. So even if we don’t have good medical treatment, we believe that reinforcement of changes in lifestyle, such as exercise and weight loss, are extremely important in these patients. It was surprising for us that three patients without any other apparent risk factors for fibrosis were diagnosed with early stage liver cirrhosis. This observation is very important because, besides the gallstones disease, the patients were consider as otherwise “healthy” subjects.

And regarding your third question?

Dr. Sarr: Can you select out the patients whom you should biopsy?

Dr. Remes-Troche: Yes. One of the messages of this study is that patients with gallstones diseases and NAFLD have some preoperative risks factors associated such as dyslipidemia, diabetes, and obesity. Thus, at least in our population, recognition of these risk factors could help to select patients. Also, this information is useful to let know patients the importance of take a liver biopsy during the cholecystectomy.

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Ramos-De la Medina, A., Remes-Troche, J.M., Roesch-Dietlen, F.B. et al. Routine Liver Biopsy to Screen for Nonalcoholic Fatty Liver Disease (NAFLD) during Cholecystectomy for Gallstone Disease: Is it Justified?. J Gastrointest Surg 12, 2097–2102 (2008). https://doi.org/10.1007/s11605-008-0704-7

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