Is the Prevalence of Gallstones in Cirrhosis Not Higher?

Although interesting, the recent study in the ARCHIVES by Conte et al¹ deserves further comment. This well-done study unfortunately failed to give new data. To accurately assess the link between cirrhosis and gallstones, the authors should have excluded the 289 patients without a histological diagnosis of cirrhosis since the diagnosis of cirrhosis is based on liver biopsy findings and since cholecystolithiasis is also associated with other chronic liver disease such as chronic active hepatitis.² To compare the overall prevalence of gallstones among the 1010 patients, which was as high as 29.5%, the authors should have presented the prevalence of gallstones in matched healthy controls from the same area, since the pathophysiologic nature of lithiasis partly depends on cultural and geographical data. Further ultrasonographic details should have been given regarding the stone's size or other findings such as polyps or thickening of the gallbladder wall, which is frequent in that population. It has been shown that cirrhosis is more strongly associated with pigmented stones than cholesterol stones³ owing to chronic hemolysis in such patients. Moreover, pigmented stones are usually smaller and fewer than cholesterol stones making the performance of percutaneous ultrasound of lesser quality when used in the diagnosis of lithiasis. The use of endoscopic ultrasonography which is by far more sensitive and specific than percutaneous ultrasound regarding small stones (inferior to 2 mm) in the gallbladder^4- 5 would have undoubtedly raised the frequency of gallstones in this population. Taken together, it is plausible that the overall prevalence of gallstones in patients with cirrhosis is far higher than this study showed.