Lipid Profile of Cholelithiasis Patients at Dr. Mohammad Hoesin Central General Hospital, Palembang

Aim: To determine the lipid profile of cholelithiasis patients at Dr. Mohammad Hoesin Central General Hospital, Palembang. Methods: This study was an observational descriptive study. The data were obtained from medical records in the Medical Record Centre of Dr. Mohammad Hoesin Hospital during the period of 1 January 2016 – 30 June 2019 by total sampling technique. Collecting data from medical record were patient’s age, gender, body mass index (BMI), occupation and lipid profile. Results: Most cholelithiasis patients were > 40 years old (69.6% of 253 patients), female (62.1% of 253 patients), normal BMI (42.6% of 195 patients), and a housewife (38% of 163 patients). The mean of total cholesterol level in 38 patients was 191.82 ± 49.63 mg/dL (104 – 350 mg/dL), the mean triglyceride level in 32 patients was117.16 ± 43.46 mg/dL (36 – 212 mg/dL), the mean of LDL level in 35 patients was 125.31 ± 36.64 mg/dL (62 – 244 mg/dL) and the mean HDL level in 36 patients was 43.33 ± 14.35 mg/dL (17 – 84 mg/dL). Conclusion: Almost all cholelithiasis patients at Dr. Mohammad Hoesin Central General Hospital, Palembang had normal lipid profile.


INTRODUCTION
Gallstone disease or cholelithiasis is the presence or formation of gallstone in the gallbladder or its tract. 1 Gallstone is a hardened-deposition of liquid component of bile. Based on the component formations, gallstone are classified into cholesterol, pigment and mixture stone. 2 Race with the highest prevalence of cholelithiasis was an Indian in North America, about 64.1% in women and 29.5% in men. The prevalence was up to 10-15% in European populations and 3-5% in Asia and Africa populations. 3,4 Risk factors affecting the formation of gallstone are abbreviated as 6Fs, including fat, forty, female, fertile, food, family. 5 Fat is highly correlated with lipid profile level and obesity. Many previous studies reported various differences regarding the increased level of total cholesterol, triglycerides, low density lipoprotein (LDL) and decreased level of high density lipoprotein (HDL) against the risk to the occurrence of gallstone. [6][7][8][9] Publication of the study on lipid profile of cholelithiasis in Indonesia, especially in Palembang city, is still limited. Therefore, we aimed to determine the lipid profile of cholelithiasis patients at Dr. Mohammad Hoesin Central General Hospital, Palembang.

METHODS
This study was a descriptive observational study.

RESULTS
There were 253 patients with cholelithiasis included in this study. Of the 253 patients, the total cholesterol test was carried out in 38 patients, triglyceride level test in 32 patients, LDL level test in 35 patients and HDL level test in 36 patients. In addition, there were 195 patients with the body mass index (BMI) data and 163 patients with the occupational data.
More than half patients were female (62.1%) with majority was a housewife (38%) (

DISCUSSION
In this study, cholelithiasis was more common in women and was consistent with the pattern of cholelithiasis that have already reported by previous studies. [10][11][12] Despite this, other study also reported no significant difference in the incidence of cholelithiasis based on gender. 13 Generally, women have higher risk of cholelithiasis than men, independent to age, because of the natural higher levels of estrogen in women especially in multiparity and/or the use of hormonal oral contraceptives. 14 Female hormones may influence the secretion of bile liver and function of gallbladder. Estrogen increases secretion of cholesterol and reduces the secretion of bile salts, while the progestin reduces the secretion of bile salts and interferes the emptying of the gallbladder. Hormone increase during pregnancy and form precipitate in the gallbladder that could be precursors of gallstone formation. In addition, the other risk factors of gallstone formation during pregnancy are the reduced levels of HDL and the metabolic syndrome. 3 Study discussing the correlation between occupation and the incidence of cholelithiasis are still limited. Some studies reported that the incidence of cholelithiasis is more common in unemployed population, including the housewife. 15,16 Based on the level of physical activity, housewife tends to have low to medium activities. 17 Sedentary life styles has a role in the formation of gallstone as evidenced by the research on the correlation between the incidence of cholelithiasis symptomatic and physical activity. 18,19 Physical activity has an effect of increasing the HDL levels and lowering triglyceride level in plasma. 20 The majority of cholelithiasis patients in this study was >40 years old, which is in accordance with previous studies. 10,21,22 However, a study at Dr. Wahidin Sudirohusodo General Hospital Makassar reported a significant higher cholelithiasis cases in patient with aged ≤ 40 years old. This result is probably due to the interaction of several other factors that affect the incidence of cholelithiasis, such as gender, concomitant diseases, obesity and hyperlipidemia. 6 The activity of cholesterol 7α-hydroxylase, an enzyme that regulate bile acid formation, decreased in patient over 40 years old. It may result in increase cholesterol saturation in bile and decrease gallbladder emptying which form precursor of gallstones. 14 Almost half of the cholelithiasis patients in this study had normal BMI. This is supported by several previous studies with similar result. 23,24 However, if overweight and obesity are combined, then the majority of patients cholelithiasis in this study will be in that new category of BMI. This is also supported by some previous studies. 15,25 Obesity is associated to the increase in enzyme activities of 3-hydroxyl-3-methyl-glutaryl co-enzyme A (HMG-CoA) reductase which leads to cholesterol synthesis in the liver. It may increase secretion of cholesterol into the gallbladder and thereby increase the risk of cholesterol type gallstone formation. 3 Normal total cholesterol level was also found in some previous studies. 8,26,27 Although, in some other studies reported otherwise. 6,28 Hypersecretion of cholesterol due to high cholesterol serum level can increase the saturation of cholesterol in bile. Cholesterol-saturated bile may undergo the nucleation process which became one of the gallstone initiation factors. 29 Normal triglyceride level was also reported in previous research. 8,27 Although, in some other studies reported otherwise. 7,9 High triglyceride level interferes the motility of the gallbladder. The underlying mechanism is a reduction in the sensitivity of the gallbladder to the cholecystokinin hormone (CCK), which stimulate contraction of the gallbladder. Hypomotility of the gallbladder form precipitates of bile, a precursor of gallstone. 30 The role of LDL level in cholelithiasis still inconclusive. 7,26-28 Main lipoproteins that carry cholesterols in the blood are LDL and HDL. 31 Increased transport of cholesterol to tissues by LDL produce regulations that decrease the synthesis of LDL receptors. It may delay the elimination of LDL which lead to increase LDL level in plasma. 32 The formation of gallstone is associated with both increased total cholesterol and LDL, eventhough the mechanism is still unexplained. 33 Some previous studies reported normal HDL level in cholelithiasis, although others reported otherwise. 7,9,[26][27][28] Cholesterol was transported by HDL for its transport back to the liver for concomitant elimination into the bile. Lower HDL level will decrease the process of cholesterol elimination, which make the plasma cholesterol level remains high. It may cause hypersecretion of cholesterol and increase the saturation of cholesterol in bile. 32 Most of the patients in this study had normal lipid profiles because they had never been diagnosed with dyslipidemia previously.