Gallstone burden and risk in Korean patients with ulcerative colitis
Article information
Ulcerative colitis (UC) is a chronic inflammatory bowel disease with a relapsing–remitting course that has traditionally been regarded as limited to the colon. However, it is now well established that UC is a systemic condition that extends beyond the intestinal mucosa, manifesting as a wide spectrum of extraintestinal manifestations (EIM) [1]. Among these, hepatobiliary EIM such as gallstone disease is one of the most common gastrointestinal conditions worldwide, and its risk factors are well described in the general population, including age (≥50 years), female sex, obesity, metabolic disorders, rapid weight loss, dyslipidemia, medications, and ethnicity. In UC, however, the relationship between chronic colonic inflammation and gallstone formation has been less clear, with prior studies reporting conflicting results between Western and Asian cohorts [2,3].
Western cohorts have long suggested an association between gallstone disease and UC, particularly in those with extensive colitis or after colectomy [4], whereas consistent findings have not been observed in Asian cohorts. Nevertheless, several studies from South Korea have shown that UC patients may have a higher risk of gallstone disease compared with the general population [5,6]. This discrepancy has raised questions not only about the prevalence of gallstone disease but also about risk factors for gallstone formation.
In the current issue of Intestinal Research, Nam et al. [7] sought to identify the prevalence and risk factors of gallstone disease in Korean patients with UC using a large, well-established tertiary referral center registry. Among 2,811 patients who underwent abdominal imaging, 198 were diagnosed with gallstone disease, corresponding to a prevalence of 7.0%—substantially higher than the 2.4% reported in the general Korean population [8]. During a mean follow-up of approximately 6 years, gallstone development was significantly associated with age ≥ 60 years at the time of imaging (odds ratio [OR], 1.027; 95% confidence interval [CI], 1.002–1.052; P=0.033), concomitant primary sclerosing cholangitis (PSC) (OR, 6.304; 95% CI, 3.162–12.565; P<0.001), and a history of colectomy (OR, 2.494; 95% CI, 1.222–5.087; P=0.012). Kaplan-Meier analyses demonstrated that both PSC and colectomy were linked to an increased cumulative risk of gallstone formation during follow-up [7].
The findings are noteworthy in several aspects. First, Nam et al. [7] established that UC patients in South Korea have a greater burden of gallstone disease than the general population, and that a history of colectomy was a significant risk factor for gallstone development. Mechanistically, UC differs from Crohn’s disease, where ileal involvement directly impairs bile acid reabsorption [9]. In UC, absorption of unconjugated bile acids can occur by diffusion in the colonic mucosa. Consequently, long-standing extensive colitis or a history of colectomy can markedly impair this process, which may account for the higher prevalence and increased risk of gallstones observed in patients with UC [10]. Second, the authors identified a gallstone disease–specific risk factor—PSC—highlighting that biliary pathology contributes to altered bile acid metabolism. These results are consistent with Western studies suggesting that longstanding colitis and colectomy can predispose patients to gallstone formation [4]. Patients with UC and concomitant PSC are at particularly high risk not only of gallstone disease but also of cholangiocarcinoma and colorectal cancer, underscoring the need for careful surveillance strategies. As the authors mentioned, in UC patients with PSC and gallstones, early routine abdominal imaging and timely cholecystectomy may be a reasonable clinical approach [7].
As with any observational study, certain limitations must be considered when interpreting these data. Being a single-center, retrospective analysis from a tertiary referral hospital in Korea, the distribution of disease extent (E3 predominated) differed substantially from that of the general UC population, limiting the generalizability of the findings to broader or Western cohorts. Given the inherent limitations of the study design, abdominal imaging was performed at the discretion of the treating physician, raising the possibility of selection bias and underestimation in asymptomatic patients. In addition, important metabolic variables such as body weight, lipid profiles, systemic diseases other than UC, the specific types of colectomy, and non-colorectal abdominal surgery were not assessed. These factors should be considered when interpreting the prevalence estimates for gallstone disease in Korean patients with UC. Despite these limitations, the study provides valuable clinical insights. It underscores the need for close monitoring in older UC patients ( ≥60 years), those with concomitant PSC, and individuals with a history of colectomy. Routine abdominal imaging may be considered in these subgroups, as early detection of gallstones could prevent complications, particularly in PSC patients who are already burdened with risks of hepatobiliary malignancy.
In conclusion, this large Korean cohort study demonstrates that gallstone disease is more prevalent in UC patients than in the general population, and identifies age, PSC, and colectomy as key risk factors. These findings highlight the importance of tailored surveillance strategies in high-risk groups and further investigation into whether surgical methods, disease extent, or genetic factors uniquely influence gallstone formation in Asian UC patients.
Notes
Funding Source
The author received no financial support for the research, authorship, and/or publication of this article.
Conflict of Interest
Jeon SR is an editorial board member of the journal but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflicts of interest relevant to this article were reported.
Data Availability Statement
Not applicable.
Author Contributions
Writing and approval of the final manuscript: Jeon SR.