Spectrum of Cholelithiasis in Decompensated Cirrhotic

Background: Cirrhosis patients are up to twice as likely to develop cholelithiasis (gallstones) as the general population. This is primarily caused by gallbladder hypomotility (poor emptying), changes in bile acid composition, and altered cholesterol metabolism. The risk increases with liver disease severity. The impaired gallbladder motility is due to fibrotic and cirrhotic which liver alters systemic hormones and nerve signaling, preventing the gallbladder from emptying effectively and leading to stone formation. The diseased liver cannot properly transport and synthesize bile acids, creating cholesterol-supersaturated bile. Moreover, impaired liver metabolism of oestrogen further impairs gallbladder emptying and increases the risk of stone precipitation. Cirrhotic have a significantly higher risk of developing cholelithiasis. The stones formed are most often pigment stones rather than cholesterol stones. The majority remain asymptomatic, but when complications occur, morbidity is substantially higher. The liver’s inability to process and secrete bile components normally is the primary driver. The failing liver has a reduced capacity to synthesize bile acids, changing the delicate balance of bile and making precipitation more likely. Autonomic dysfunction and altered hormonal signaling in cirrhosis impair the gallbladder's ability to contract, leading to bile stasis. Hypersplenism due to portal hypertension leads to increased red blood cell destruction, resulting in excess bilirubin, which forms pigment stones. The aim is to estimate prevalence of development of cholelithiasis in decompensated cirrhotic patients at tertiary care center of Northern India. Material and Methods: This study was conducted at Medical Gastroenterology Department at PGIMS, Rohtak. It was a prospective study done over five years, from 01.03.2021 to 28.02.2026, during which 400 confirmed decompensated cirrhotic patients were followed up for development of cholelithiasis. For better understanding 100 patients each of Alcoholic liver disease (ALD), Chronic Hepatitis C (HCV), Chronic Hepatitis B (HBV), and Metabolic dysfunction- associated steatotic liver disease (MASLD) were enrolled in the study after proper written consent. Patient were labelled decompensated cirrhotic on basis of ultrasonogram evidence of ascites with altered echotexture of liver, Pedal edema, Endoscopic proven variceal bleed, Serum bilirubin greater than 3 gm%. Cholelithiasis was also proven on ultrasonogram basis. All patients who were having cirrhosis for at least three years duration were enrolled in the study. All hepatitis B and C patients were confirmed on HbsAg and anti-HCV antibody on Enzyme linked immunosorbent assay (ELISA) test and HBV DNA and HCV RNA Quantitative on Polymerase chain reaction test (PCR). Results: Our department is Model treatment Center (MTC) under National Viral Hepatitis Control Program (NVHCP) and is one of the high flow centers in India. On daily basis, 2-3 new and 20 follow up patients of cirrhosis of different aetiologies come for consultation and till date approximately 10,000 cirrhotic patients have been treated at our department. On prospective analysis of 400 confirmed decompensated cirrhotic patients, out of which 100 each were ALD, HCV, HBV and MASLD related. In ALD subgroup, all were males, in HCV- 59% were males, in HBV-65% were male and in MASLD-55% were male. Thus, there was male predominance in all the groups. Moreover, in all four groups, maximum number patients were above 40 yrs of age and peak was between 50-70 yrs, with mean age of 59 yrs. The prevalence of cholelithiasis was maximum in MASLD subgroup (32%), followed by HBV (25%), HCV (21%) and ALD (20%). Conclusion: Our vision regarding complications of chronic liver disease, especially in decompensated stage, from hepatic encephalopathy, hepatorenal syndrome, gastro-intestinal bleed, recurrent infections, refractory ascites etc. has to become broader and should must include cholelithiasis and sexual dysfunction. Moreover, cholelithiasis has to be dealt with symptoms associated with it and stage of liver disease, according to Child-Pugh score.

Keywords: Cholelithiasis, HBV, HCV, ALD, MASLD, Decompensated, Cirrhotic.