1

BHARATI VIDYAPEETH( DEEMED TO BE UNI-

VERSITY)
MEDICAL COLLEGE AND RESEARCH
CENTRE,PUNE
SYNOPSIS FOR POST GRADUATION DISSERTA-
TION

A COMPARITIVE STUDY OF BIOCHEMICAL

PROFILE AND STONE ANALYSIS OF GALL
STONE PATIENTS AND NON GALL STONE PER-
SONS.

IN THE SUBJECT OF MS , GENERAL SURGERY

BY DR. K.DIVYA BHARATHY, UNDER THE GUID-

ANCE
BATCH OF MAY 2019 OF DR.SUDHIR SHINDE

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 APPROVAL FORM

Departmental Scientific Committee meeting was held to 17 th & 18th July 2019
discuss the dissertation topic of the post graduate students. The following post
graduate teachers attended the meeting.

Dr. Mrunal Ketkar

Dr. S V Deshmukh

Dr. Ravindra Kharat

Dr. J K Banerjee

Dr. Suhas Taralekar

Dr. Sudhir Shinde

Dr. Shilpa Patankar

Dr. Rajeev Doshi

Dr. Juthikaa Deherkar

Dr. Rachana Gaidole

Dr. Girija Patil

Dr. Abhay Kumar

Dr. Pravin Borkar

Dr. Aniket Khadatkar

The topic “A COMPARITIVE STUDY OF BIOCHEMICAL PROFILE AND STONE ANALY-

SIS OF GALL STONE PATIENTS AND NON GALL STONE PERSONS” by PG student

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Dr. K.Divya bharathy was discussed in detail , the feasibility was asserted and
modifications , if any, were suggested. After the necessary modifications this
topic has been approved for dissertation by the departmental scientific commit-
tee.

Dr. Mrunal Ketkar

Professor and HOD

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 Contents Attached

Title Page YES

Letter of approval by scientific committee YES
Letter of participation in research methodology YES
workshop
Protocol as per guidelines including annexures
1.Questionnaire/Proforma YES
2.Participant Information Sheet with consent YES
Form -English
3.Participant Information Sheet with consent YES
Form-Marathi
4. Approval letter for Sample size estimation from YES
statistician
If study subject is < 18 years of age NA
5.Parent consent Form-English
If study subject is < 18 years of age NA
6.Parent consent Form-Marathi
If study subject is between 8-18 years of age NA
7.Child assent Form-English
If study subject is between 8-18 years of age NA
8.Child assent Form-Marathi

Students signature & Name Guide Signature

Name and Stamp

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INDEX

SR. DESCRIPTION PAGE NO

NO
1 Introduction 7-8
2 Aims and objectives 9
3 Materials and methods 10-11
4 References 12
5 Annexure
Proforma 13
Patient information sheet (Eng- 16-17
lish)
Patient information sheet 18-19
(Marathi)
Patient consent sheet (English) 20
Patient consent sheet (Marathi) 21

8
Introduction:
Gall stones disease (GD) is a very common gastro-intestinal disorder
which is present commonly in the western world1.Studies from north-
ern India have looked into the dietary factors which predispose to
cholesterol gall stones2.The major elements which are involved in the
formation of gall stones are cholesterol, bile pigments, calcium, he-
patic bile composition, biliary glycoprotein, infection, age, sex, genet-
ics, oestrogen, dietary factors, geographical prevalence3. Chemical
composition of gall stones is essential for aetiopathogensis of gall-
stone disease . Total cholesterol as the major component and total
bilirubin, phospholipids, triglycerides, bile acids, fatty acids (esteri-
fied), soluble protein, calcium, magnesium, iron, copper, sodium,
potassium, inorganic phosphate, oxalate and chloride as minor com-
ponents were found in all types of calculi. The cholesterol stones had
higher content of total cholesterol, phospholipids, fatty acids (esteri-
fied), inorganic phosphate and copper compared to mixed and pig-
ment stones4. The mixed stones had higher content of iron and triglyc-
erides than to cholesterol and pigment stones. The pigment stones
were richer in total bilirubin, bile acids, calcium, oxalate, magnesium,
sodium, potassium, chloride and soluble protein compared to choles-
terol and mixed stones. Most of the gall stone patients are asympto-
matic and thus the present study describes an extensive outlook into
the biochemical analysis of the stones, their incidence, age and sex
distribution, the risk factors, the type of stones, the lipid profile, their
histopathological diagnosis and bile culture5. In gallbladder and com-
mon duct bile from patients undergoing cholecystectomy, usually be-
cause of gallstones, calcium was found to exist in at least 2 forms. Ul-
trafiltration showed some calcium was bound to substances with a
molecular weight greater than 10 000, and the chief binding agent is
likely to be the mixed micelle. Bound calcium was significantly less

9
in common duct bile than in bile from functioning gallbladders, but
the amount of ultrafiltrable calcium was the same. Furthermore, ultra-
filtrable calcium in gallbladder bile from patients with cholesterol or
some calcium carbonate in their gallstones was almost constant for a
range of total calcium concentrations of 2.40–9.70 mmol/l6. Compari-
son of ultrafiltrable and total calcium values for the different types of
stone-formers showed that the deposition of calcium carbonate in
gallstones was not related to any calcium measurement made. How-
ever, the presence of calcium phosphate and/or calcium bilirubinate in
gallstones could be related to a significant increase in ultrafiltrable
calcium in gallbladder bile. Abstract
Black and brown pigment gallstones are morphologically, composi-
tionally, and clinically distinct. Black stones form primarily in the
gallbladder in sterile bile and are associated with advanced age,
chronic hemolysis, alcoholism, cirrhosis, pancreatitis, and total par-
enteral nutrition7. Brown stones form not only within the gallbladder
but also within the intrahepatic and extrahepatic ducts; they are uni-
formly infected with enteric bacteria and are usually associated with
ascending cholangitis. Brown stones are related to juxtapapillary duo-
denal diverticula and are the predominant type of de novo common
bile duct stones. Cholecystectomy is usually curative in black pigment
stone disease, whereas stones often recur after cholecystectomy for
brown stone disease. The pathogenesis of black stones is probably re-
lated to nonbacterial, nonenzymatic hydrolysis of bilirubin conju-
gates. At the pH of bile, this results in two monohydrogenated biliru-
bin anions that precipitate with calcium ions. Bilirubin monoconju-
gates that are increased in several conditions, such as Gilbert's syn-
drome and chronic hemolysis, may play a pivotal role in black stone
formation as a source of unconjugated monohydrogenated bilirubin
and as a possible co-precipitant with calcium8. The precipitation of
calcium carbonate and phosphate is influenced by local gallbladder
factors. Brown pigment stones are formed in bile infected with enteric
bacteria that elaborate hydrolytic enzymes: beta-glucuronidase, phos-
pholipase A, and conjugated bile acid hydrolase. The resulting anions
of bilirubin and fatty acids form insoluble calcium salts. We used nb/

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nb mice with a chronic hemolytic anemia as a model of hemolysis-in-
duced black stone disease. The presence of 40% bilirubin monoconju-
gates in mouse gallstones indicated the importance of this moiety in
the pathogenesis of black stones9. Other data obtained by marrow
transplantation experiments in mice revealed the relative importance
of genotype versus the hemolytic anemia on determinants such as bil-
iary bile acid composition and mucin secretory glands in the mouse
gallbladder neck. Additional physical chemical studies of the interac-
tion of unconjugated bilirubin in model bile solutions will be helpful
in further delineating the pathogenesis of both black and brown pig-
ment gallstones10.

AIM:
To study the biochemical profile and stone analysis of gall
stone patient and normal persons.

OBJECTIVES:
To study the pattern in age, sex,socio economic status, and
diet
To differentiate the types of gallstones based on serum levels
of phosphate, cholesterol, bilirubin and calcium
To study the types of gallstone based on morphology-stone
analysis

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MATERIALS AND METHODS
● STUDY SETTING: Tertiary Care Hospital
● STUDY DESIGN: Prospective study
● STUDY DURATION: August 2019 to August 2021
● STUDY POPULATION: 66
STUDY PARTICIPANTS: Patients admitted in surgical wards of Bharati Hos-
pital were included for the study. Study subjects were divided into two groups
comprising of 33 in each group

INCLUSION CRITERIA : Group I Inclusion criteria

Patients in whom the presence of gallstone was confirmed by ultra-

sound abdomen.
Patients who underwent cholecystectomy for the same
● EXCLUSION CRITERIA: Group I Exclusion criteria:
Acalculous Cholecystitis
Patients with obstructive Jaundice.
Patients who were not fit for cholecystectomy.
Patients who refused cholecystectomy.

Group II Inclusion Criteria:

Age and sex matched apparently healthy control subjects in whom
ultrasound.
Abdomen confirmed the absence of gallstones.
roup II Exclusion criteria:
Control subjects in whom ultrasound abdomen re-
vealed presence of gall stones

● SAMPLING TECHNIQUE- Purposive non probability sampling.

● TOOL OF DATA COLLECTION: Proforma:

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● METHODOLOGY FOR DATA COLLECTION: This is a comparative study
of serum cholesterol, bilirubin, phosphate and calcium in patients with gall-
stones and apparently healthy controls. Patients admitted in surgical wards of
Bharati Hospital were included for the study. Study subjects were divided
into two groups comprising of 50 in each group.

Group I: Consisted of study subjects who were diagnosed to

have gallstones.clinically and confirmed by ultrasound abdomen, and those who
underwent surgery for the same.

Group II: Consisted of age and sex matched apparently

healthy control subjects who did not have any symptoms and signs suggestive
of gallstones clinically and the absence of gallstones confirmed by ultrasound
abdomen.

● PLAN OF DATA ANALYSIS : Using a Master Chart.

References:

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1
Sandler RS, Everhart JE, Donowitz M, Adams E, Cronin K, Good-
man C et al. The burden of selected digestive diseases in the United
States. Gastroenterology 2002; 122: 1500-11.
2
Aerts R, Penninckx F. The burden of gall stone disease in Europe.
Aliment Pharmacol Ther 2003; 18 Suppl 3: 49-53.
3
Gokulakrishnan S, Murugesan R, Mathew S, Prasanthi R, Ashok AC,
Ramesh H, et al. Predicting the composition of gall stones by infrared
spectroscopy. Trop Gastroenterol 2001; 22: 87-9.
4
Raha PK, Sengupta KP, Aikat BK. X-Ray Diffraction analysis of
gallstones. Ind J Med Res 1966; 54:729
5
Buccolo G, David H. Quantitative determination of serum triglyc-
erides by the use of enzymes. Clin Chem 1973; 20: 470–75
6
Buccolo G, David H. Quantitative determination of serum triglyc-
erides by the use of enzymes. Clin Chem 1973; 20: 470–75
7
Trotman BW, Ostrow JD, Soloway RH. Pigment versus cholesterol
cholelithiasis: Comparison of stone and bile composition. Am J Dig
Dis 1974; 19: 585–90
8
Ti JK, Yuen R. Chemical composition of biliary calculi in relation to
pattern of biliary disease in Singapore. Br J Surg 1985; 72: 556–8
9
Thijs C, Knipschild P, Brombacher P. Serum lipids and gall stones: a
case controlled study. Gastroenterology 2001; 99:843-49.
10
Stewart L, Griffis JM, Way LM. Spectrum of gall stones disease in
the veteran population. Am J Surg 1990; 190:746-51.

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 PARTICIPANT INFORMATION SHEET
Dear Sir/Madam,

You are being requested to volunteer in the above mentioned research study. Dr.
K.
“TODIVYA
STUDY BHARATHY is the investigator
THE BIOCHEMICALPROFILE for the
AND STONE study under
ANALYSIS the guidance
IN GALL of
STONE PATIENTS
Dr. Sudhir Shinde. AND NORMAL PERSONS “

This document
Department ofwill provide
General you with the information needed to help you decide
Surgery,
whether you wish to take part in this study.
Bharati Vidyapeeth( Deemed to be university),
Objective of the study: to study and compare the biochemical profile and stone
Medical College,
analysis of Dhankawadi,Pune-43
gall stone patients and normal persons

How will this study be done:

Collection of Data
●
● Detailed clinical history
● Details of biochemical profile
● Assess the type of stone after surgery
Study Duration: 2 years(August 2019-August 2021)

Number of Participants in this study: 60

Advantage of this study: Based on above studies it is positle to differentiate

types of stones and select patient for alternate therapy of cholelithiasis.

What happens if you refuse to take part in the study or change your mind after
you agree: The course of treatment will continue as before and as planned.

Patient’s responsibility in this study: to permit collection of data, To get bio-

chemical profile and stone analysis from laboratory ,Bharati Hospital and Re-
search centre.

Possible risk(if any ): Nil

Confidentiality of study and medical records will be maintained.

Result of this study may be presented at meetings or maybe published as a sci-

entific evidence to further the existing medical knowledge solely for purpose of
academics.

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Who can you contact if you have any questions regarding the research study:

Name of the investigator: Dr. DIVYA BHARATHY.

Mobile NO : 9944190820

Department of General Surgery.

INFORMED CONSENT FORM

I have read the entire patient information sheet and understood what
treatment will be given to me and what I am being asked to do.
I consent to take part in this study entitled COMPARATIVE STUDY
OF BIOCHEMICAL PROFILE AND STONE ANALYSIS OF
GALL STONE PATIENTS AND NORMAL PERSONS to be con-
ducted in Bharati Vidyapeeth(Deemed to be University ) Medical col-
lege and hospital Pune.

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 ● I understand that I am free to withdraw myself from the study at
any time without justifying my decision and without affecting my
medical care
● I understand that my data and records will be kept confidential.
● I understand that my data if required, may be used for research
purpose.

Name and Signature of participant :

Name and Signature of the Investigator: Dr. DIVYA BHARATHY

Date: Time: Place: Pune

If patient is illerate or unable to understand due to any reason.

Name and Signature of Impartial Witness.

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 PROFORMA
NAME: CASE:
AGE: HOSPITAL:
SEX: IP NO:
RELIGION: UNIT WARD:
OCCUPATION: D.O ADMISSION:
ECONOMIC STATUS: D.O OPERATION:
D.O STUDY:

CHIEF COMPLAINTS:
Pain abdomen
Appetite
Nausea and vomiting
Jaundice
Bowel habits
Itching
Fever

HISTORY OF PRESENTING ILLNESS:

1.Pain abdomen
a.mode of onset d.Radiation
b.site e.Duration
c.character f.relation to food
2.Nausea and Vomiting
3.Jaundice
Past History

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 1.Recurrent attacks of pain right upper abdomen

2.Hemolytic disorders 4.Hypertension

3.Diabetes mellitus 5.Hyperlipidemia

Personal History
1.Diet 5.Smoking
2.Appetite 6.Sleep
3.Fatty food intolerance 7.Bowel habits
4.Alcohol 8.Micturition

Family History
1. Hemolytic disorder
2. Hyperlipidemia
3.Obesity

General Physical Examination

1.Build and Nourishment 6.Lymphadenopathy
2.Pallor 7.Oedema
3.Icterus 8.Xanthoma
4.Cyanosis 9.Xanthelesma
5.Clubbing
Pulse Rate Respiratory Rate
Blood Pressure Temperature

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SYSTEMIC EXAMINATION
Per Abdomen:
Inspection:
Palpation:
a.Tenderness in right hypochondrium
b.Hyperasthesia in 9th costal cartilage
c.Murphy’s sign
Percussion:
Auscultation:
Cardio vascular system:
Respiratory system:
Central nervous system:
Investigations
Serum levels of
• Cholesterol
• Bilirubin
• Calcium
• Phosphate
Routine Investigations:
Ultrasonography:
Diagnosis:

TREATMENT
• Medical
• Surgical

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 1.open
2.Mini laparotomy
3.laparoscopic
STONE ANALYSIS
Number
Type of stone

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