Chest Pain, Family History, and Surgery: A Qualitative Interview Study of Cholecystectomy Patients

Abstract

Introduction:

Symptomatic gallstone disease (sGD) is among the most common gastrointestinal illnesses requiring hospitalization, and cholecystectomy (CCY) is the most common abdominal general surgery in the US. Emergency CCY has a case fatality rate estimated to be 60-times higher than nonemergency CCY, yet both occur with equal frequency. The aim of this study is to generate hypotheses of patient-level factors influencing whether patients with sGD receive emergency or nonemergency CCY.

Methods:

Semi-structured interviews were conducted with patients aged more than 18 who underwent either emergency or nonemergency CCY for sGD. Interview transcripts were coded and analyzed using ATLAS.ti.

Results:

Twenty-four patient interviews were conducted: 10 (42%) were emergency CCY patients and 14 (58%) were nonemergency CCY patients. There were no differences in age, sex, race, ethnicity, interview language, or insurance status between emergency and nonemergency CCY patient samples. Three key themes emerged: 1) physical symptoms of gallstone disease, 2) patient interpretation of gallstone disease symptoms, and 3) utilization of interpersonal social networks for discussion of gallstone disease. Specifically, patients reported that gallstone-related chest pain, a symptom which was interpreted by some patients as cardiac illness, influenced prompt care-seeking. Patients who had knowledge of their family history of gallstone disease prior to diagnosis reported being able to draw connections between their own symptoms and their family history, thus recognizing their need to seek care.

Conclusions:

Chest pain and knowledge of family history may influence care-seeking behavior and surgical timing in sGD. These factors merit further investigation as potential modifiers of undergoing emergency and nonemergency CCY for prevention of emergency surgery and subsequent patient outcomes.

Introduction

Cholecystectomy (CCY) is the most commonly performed abdominal surgery in the United States, and symptomatic gallstone disease (sGD) is among the most common causes of gastrointestinal-related hospitalization.^1–6 CCY can either be conducted as emergency or nonemergency surgery, although emergency CCY has a case fatality rate estimated to be up to 60-times greater than that of nonemergency CCY.⁷ Despite this disparity in fatality rate, emergency CCYs are performed as often as nonemergency CCYs at the national level.^8,9 There is mounting evidence that this is an emergency burden that falls disproportionately on patients of lower socioeconomic status.^10–12

Despite advances in surgical techniques, little attention has been paid to patients’ interpretation of their symptoms and knowledge of their family history of gallstone disease, factors which may impact how and why patients present for emergency rather than nonemergency CCY.^13–16 Further, the heritability of gallstone disease is well demonstrated.^17,18 Thus, there is potential for patients to discuss sGD with family members to better inform their own symptom recognition and care-seeking behaviors to avoid emergency presentation.

The duration and severity of sGD is highly variable, with patients experiencing anywhere from hours to years of symptoms before undergoing indicated surgical management.^19,20 Patients who delay seeking care have compounding risk of an acute complication requiring emergency endoscopic and/or surgical intervention.^21–23 The aim of this study is to generate hypotheses of modifiable factors that may influence emergency or nonemergency surgical care received by patients with sGD.

Methods

Patient recruitment

The study included patients 18 y and older who underwent either emergency or nonemergency CCY for sGD.²⁴ Emergency and nonemergency CCY were defined as unplanned CCY performed by the acute care surgery service and planned CCY performed by the general surgery service, respectively. Patients who underwent CCY for acalculous disease were excluded. Patients were identified via electronic medical records prior to their 2-wk postoperative follow-up visits. Purposive sampling was employed to obtain similarly sized samples of emergency and nonemergency CCY patients. Research staff then conducted in-person recruitment in collaboration with acute care surgery and general surgery faculty in their outpatient clinics.

Of the 33 patients approached for study inclusion, 24 completed interviews between August 2023 and June 2024. Three patients refused enrollment due to timing constraints (i.e., patients needed to leave the visit promptly) and six patients did not attend their scheduled Zoom interview and were not responsive to subsequent communications. This study was approved by the Rutgers University Institutional Review Board (approval number 00011977).

Interview design

This study used in-depth interviews to elicit patient perspectives.²⁵ Interview content and our semi-structured guide were informed by a moderated New Jersey Alliance for Clinical and Translational Science Community Engagement Salon which included community stakeholders, primary care physicians, emergency medicine physicians, general surgeons, acute care surgeons, and experts in qualitative research.²⁶ This salon elicited perspectives on the presentation of patients with sGD and potential barriers to earlier treatment of their disease. A draft of the interview guide was then presented to groups of acute care surgery and general surgery faculty who reached consensus on the second interview guide draft. This second draft was then pilot tested with five patients to ensure usability for interviewers and ability to generate robust patient responses, a process which did not result in further interview guide alterations. The final interview guide included five open-ended original questions with probes focusing on patient experiences with symptoms of sGD, care-seeking, and treatment influencing why and how patients received either emergency or nonemergency CCY (Fig. 1).

Fig. 1 –

Patient interview guide.

Data collection and analysis

One-on-one interviews were completed via Zoom. The interviews were conducted with patients treated at an urban academic hospital in NJ, USA. Interviews were performed by N.F. and L.C. who were supervised by G.P. and S.H. Patients underwent verbal consent at the beginning of their Zoom interviews and were compensated with a $20 prepaid gift card for their time. Mean interview length was 28 min (standard deviation = 8.1 min). Rolling analysis was conducted and recruitment was terminated once thematic saturation was reached.^27,28 Study data were collected and analyzed in accordance with the Consolidated Criteria for Reporting Qualitative research.²⁵ Interviews were recorded and transcribed using native Zoom functionality. Transcripts were then assessed for accuracy through comparison with audio recordings. Spanish language interviews were translated by trained research staff with native Spanish proficiency. All qualitative coding was conducted using Atlas.ti (version 24.1.1).²⁹

A preliminary codebook was developed based on the first five interviews. Two team members (N.F., L.C.) then independently coded the first 12 interviews using the preliminary codebook. The codebook was then revised to include codes that had not emerged from the first 12 interviews and to eliminate underutilized codes. Intercoder agreement was achieved via code-to-consensus.³⁰ Descriptive analysis was performed to compare code frequencies between emergency and non-emergency using R (version 4.2.1).³¹

Results

Ten patients underwent CCY in the emergency setting and 14 patients underwent CCY in the nonemergency setting (n = 24). There were no statistically significant differences in age, sex, race, ethnicity, interview language, or insurance status between emergency and nonemergency CCY patient samples (Table 1). Of the ten patients who underwent emergency CCY, nine patients (90%) received their diagnosis of sGD in the emergency department (ED) while one patient (10%) received their diagnosis in the outpatient setting. Of the 14 patients who underwent nonemergency CCY, eight patients (57%) received their diagnosis of sGD in the ED while six patients (43%) received their diagnoses in the outpatient setting.

Table 1 –

Patient characteristics.

Characteristic	Overall (N = 24)	Emergency cholecystectomy (N = 10)	Nonemergency cholecystectomy (N = 14)	P value
Age (years)
Mean (SD)	43.3 (12.8)	40.4 (12.7)	45.3 (12.9)	0.368*
Sex
Male	14 (58.3%)	5 (50.0%)	9 (64.3%)	0.484†
Female	10 (41.7%)	5 (50.0%)	5 (35.7%)
Race
Asian	2 (8.3%)	2 (20.0%)	0 (0%)	0.081†
Black	6 (25.0%)	3 (30.0%)	3 (21.4%)	0.633†
White	14 (58.3%)	5 (50.0%)	9 (64.3%)	0.484†
Other	2 (8.3%)	0 (0%)	2 (14.3%)	0.212†
Ethnicity
Hispanic	9 (37.5%)	6 (60.0%)	3 (21.4%)	0.054†
Non-Hispanic	15 (62.5%)	4 (40.0%)	11 (78.6%)
Interview language
English	21 (87.5%)	8 (80.0%)	13 (92.9%)	0.348†
Spanish	2 (20.0%)	1 (7.1%)	0 (0%)
Insurance status
Private	15 (62.5%)	6 (60%)	9 (64%)	0.830†
Medicaid	6 (25%)	3 (30%)	3 (21.4%)	0.632†
Medicare	1 (4.2%)	1 (10%)	0 (0%)	0.226†
Uninsured	2 (8.3%)	0 (0%)	2 (14.3%)	0.211†

^*P value was calculated using simple t-test for continuous variables.

^†P values were calculated using chi-square tests for two categorical variables.

Thematic analysis

Three themes emerged from patient interviews: 1) the physical symptoms of gallstone disease (Table 2), 2) patients’ interpretation of gallstone disease symptoms (Table 3), and 3) patients’ utilization of their interpersonal social networks (e.g., family, friends, coworkers) during symptoms of gallstone disease (Table 4).

Table 2 –

Theme 1: Physical symptoms of gallstone disease.

Subtheme	Quote
Abdominal pain	“So I woke up in the middle of the night, like, it was like 1:15 AM. And I had a severe pain in the middle of my belly, like very clearly where the diaphragm is… It was horrendous.” (P01, emergency) “It was a very dull pain, very dull pressure, like someone was sticking a fist and pressing into the center of your stomach. And that’s why I didn’t realize it was the gallbladder at first because the pain was really in my stomach area just above my belly button.” (P03, non-emergency) “And what led me to the ED was a sharp piercing pain. On my upper right part of my abdomen where it would permeate all the way through to my back.” (P27, non-emergency)
Vomiting	“I had a sandwich with some greasy food. That night I was up in the bathroom vomiting with intense stomach pain.” (P03, non-emergency) “So if I ate something that I know I wasn’t supposed to eat. I Could feel it in my stomach. It’d be like a gas. And once I felt that gas pain in my stomach… I Had to throw up probably about three times.” (P07, non-emergency) “I went to take my son to see some colleges and while there I had a meal and after I had pain in my stomach. In the pit of my stomach. I Ended up vomiting again and I didn’t t want to eat anything else.” (P04, emergency)
Chest pain	“That time I started getting like sort of an uneasiness. It wasn’t quite in my breastbone area but like in my chest.” (P09, emergency) “It kind of hurt in my diaphragm and it feels like you know… Like something burning right underneath. [The pain was] in my right breast.” (P05, non-emergency) “And then all of a sudden, the pain became progressively worse. And it was kind of right in the middle of my chest bone, in the front. And then pain began radiating to my back.” (P29, non-emergency)

Table 3 –

Theme 2: Patient interpretation of gallstone disease symptoms.

Subtheme	Quote
Self-diagnosed food poisoning	“I remember calling out on my second day of work. Because I just assumed that I had food poisoning. And then it would always start at night. And I wouldn’t have any pain in my like stomach, it would just feel more like nausea and like I have to vomit… So, every time I got sick I would end up chalking it up as food poisoning.” (P11, emergency) “I was experiencing just vomiting and it was just a little too frequent… And I just thought, you know, oh maybe food poisoning or just something didn’t agree with me. Then it kept happening and I thought it has to be like really bad food for that to happen.” (P28, Non-Emergency) “I didn’t have any fear because [I thought] I ate something bad and my body rejected it and just vomited it out. And I felt fine after I didn’t have any pain.” (P05, non-emergency)
Self-diagnosed heart attack	“What if I’m just kind of just sitting here and I’m damaging my heart by not going to get this checked out. So that’s what kind of like drove me into the doctor more of the heart because I guess I was gonna put it off if it didn’t climb up my chest.” (P04, emergency) “Because the pain was so bad in my chest, I thought like I was having a heart attack… With me being pregnant, I said, I might be having a heart attack and that’s why we decided to call the ambulance.” (P29, Non-Emergency) “And then in January I had a similar episode [of pain]. And that time was so bad. The pain was so bad, I thought that I was having like a heart attack or something like so I had to call 9-1-1 and that’s when they took me to the emergency room.” (P24, non-emergency)

Table 4 –

Theme 3: Utilization of interpersonal social networks.

Subtheme	Quote
Advice from social connections	“I received and trusted the advice of my wife and my son about [gallstones] being a serious condition and I should really deal with it now rather than let it get to an emergency standpoint.” (P03, non-emergency) “So I definitely liked knowing people who went through [a cholecystectomy]… So I wasn’t scared about the surgery, everyone sounded like they did okay after the surgery.” (P21, non-emergency)
Prospective knowledge of family history	“My mother had her [gallbladder] taken out years ago, and all three of my sisters had theirs taken out. So I wasn’t messing around because I knew the pain that they were in and that’s why I made the appointment to go see the doctor.” (P09, emergency) “So my sister-in-law has gallstones and I was explaining [my symptoms] to her. And she was like ‘you probably have gallstones’, those were the same things she felt. My mom also had her gallbladder removed years ago… So after maybe two or three times of having a gallstone attack, I went and saw my primary care doctor.” (P20, non-emergency) “So I knew that my mom had her gallbladder removed… I Did think about that, and I told my mom and my mom was kind of like ‘yea, it sounds like it could be your gallbladder’.” (P15, emergency)
Retrospective knowledge of family history	“I didn’t even know that [my grandmother] had the surgery done until a few days after [my surgery].” (P07, Non-Emergency) “I found out during those days [in the hospital] that my mom had received surgery as well when she was younger for gallstones. And my dad told me that my grandma also had the surgery.” (P14, emergency, translated from Spanish) “I believe my mom also has gallstones, but it’s just being monitored right now… I Found out once I had surgery.” (P10, emergency)

Theme 1: Physical symptoms of gallstone disease

Patients described a variety of physical symptoms they experienced during gallstone disease. Patients who underwent emergency CCY experienced vomiting more frequently than patients who underwent nonemergency CCY. Additionally, emergency CCY patients stated that their symptom onset typically occurred at night: “I would say 2–3 y before my surgery I started having symptoms that would wake me up at night with pain that I could pinpoint with my finger… Then during the day my mind got consumed by other things and I wouldn’t think about it.” (Participant 04, emergency).

Other patient symptoms including back pain, abdominal pain, fear of heart attack, and self-diagnosis of food poisoning were similar across treatment groups (Table 5). Multiple patients in both treatment groups reported that they experienced significant chest pain during their gallstone disease episodes with 30% of emergency CCY versus 43% of nonemergency patients reporting chest pain: “[My pain] was right in the center of [my] chest where my rib cage starts, and the pain would radiate all through my back” (Participant 06, nonemergency).

Table 5 –

Subtheme frequencies by treatment group.

Subtheme	Emergency cholecystectomy (N = 10)	Nonemergency cholecystectomy (N = 14)
Physical symptoms of gallstone disease
Abdominal pain	6 (60%)	8 (57%)
Back pain	5 (50%)	6 (43%)
Chest pain	3 (30%)	6 (43%)
Vomiting	8 (80%)	8 (57%)
Symptom interpretation
Fear of heart attack	1 (10%)	2 (14%)
Self-diagnosis of food poisoning	3 (30%)	3 (21%)
Utilization of interpersonal networks
Prospective family history	5 (50%)	8 (57%)
Retrospective family history	5 (50%)	2 (14%)

Some patients with chest pain also reported that they experienced difficulty breathing: “And [the pain] kept climbing up into my chest and toward the right side of my chest… and the pain wouldn’t allow me to breathe in” (Participant 04, emergency).

Theme 2: Patient interpretation of gallstone disease symptoms

Patients were also asked to consider how they interpreted their gallstone disease symptoms. Some patients who reported chest pain were fearful that they were having a heart attack. Patients stated that the fear of a heart attack pushed them to seek care in an emergency setting: “Yeah, so it really came down to, that the day I decided to go to the emergency room. It came down to more of the heart. You know, I was more considering the fact that the pain was rising into my sternum” (Participant 04, emergency).

Others also cited their fear of a heart attack as pushing them to undergo medical evaluation: “The pain was so bad. I thought that I was having like a heart attack or something like that. Then I called 9-1-1 and they took me to the emergency room,” (Participant 24, nonemergency).

Some patients with repeated bouts of vomiting initially interpreted their illness as recurrent episodes of food poisoning and not sGD: “I got sick with what I attributed to food poisoning maybe 7–10 times and then…my family was telling me that’s not normal and I should get checked out” (Participant 11, emergency).

Of those patients who incorrectly self-diagnosed themselves with food poisoning, many delayed care-seeking because they felt comfortable managing their “food poisoning” at home: “So, both my husband and I were thinking, ‘oh, we, you know, you ate something bad again. You had food poisoning again, right?’ And, and I followed the same steps I did prior. By drinking a lot of ginger ale to stay hydrated” (Participant 5, nonemergency).

Theme 3: Utilization of interpersonal social networks

Many of our participants discussed the impact that their friends, family, and even coworkers had on their decisions of when, where, and how to seek care for their symptoms of gallstone disease. Some patients suffered months and even years of symptoms before they sought medical care and received a diagnosis or treatment for gallstone disease. Patients often utilized their interpersonal networks by describing their symptoms to those around them and received support and advice in return. Social connections served as motivation for them to seek care when they may not have done so otherwise: “My friend… could tell that I had gone to the bathroom to throw up and she was just like ‘no, you need to go [see a doctor]’. So, she went and got my sister and they said, ‘[let’s] go get things checked out’” (Participant 15, emergency).

Beyond just encouraging participants to seek care initially, interpersonal social networks encouraged patients to undergo surgery once a diagnosis had been established: “My family saw how much pain I was in. They encouraged me to go to the hospital so they could perform the surgery because they always saw me suffering… But your family always sees you suffer and see that doctors can heal you. So, they encouraged me to get the surgery” (Participant 12, emergency, translated from Spanish).

Through interactions with their interpersonal social networks, some patients were made aware of their family history of gallstone disease before they were diagnosed themselves, which seemed to motivate care-seeking: “I remember having an attack and my mother telling me it sounded like the pain she had [from her gallstones]. So, we decided not to mess around and I got an appointment with my doctor” (Participant 09, emergency). Fifty percent of emergency CCY patients reported prospective knowledge of their family history of gallstone disease (i.e., were aware of a family history prior to diagnosis) versus 57% of nonemergency patients.

Other patients were made aware of their family history after their diagnosis. Fifty percent of emergency CCY patients reported retrospective knowledge (i.e., became aware of their family history after diagnosis of gallstone disease) versus 14% of nonemergency patients. Some learned before they had made their decision to receive surgery: “I think the fact that he [my father] had his gallbladder out and I knew that there was a potential family history and I knew that he had had severe complications… I think that rose my level of concern that like, okay, this could turn more serious really quickly. So that definitely played an influence in [getting surgery]” (Participant 29, nonemergency).

Others were only made aware of their family history after they themselves had undergone surgery and were thus unable to use that information to inform their treatment decisions: “I didn’t even know [my grandmother] had the surgery until a few days after my surgery. But then she told me that she had her gallstones out” (Participant 07, nonemergency).

Discussion

The present study provides a rich description of patient experiences with gallstone disease symptoms, care-seeking, and treatment. Three central themes in our participant responses were identified and included 1) patient-reported physical symptoms of gallstone disease, 2) patient interpretation of gallstone disease symptoms, and 3) patient utilization of their interpersonal social networks during symptoms of gallstone disease. We found some key differences between the groups in terms of: (1) symptom presentation; (2) delayed care seeking as a result of symptom interpretation in the emergency CCY group; and (3) limited knowledge and ability to act on symptoms in the emergency group.

Although clinicians experienced with diagnosing and treating biliary disease may anecdotally associate chest pain with sGD, literature describing gallstone-associated chest pain is limited to case reports. Observational studies have reported the clinical manifestations and patient-reported symptoms of sGD, and to our knowledge none have included chest pain in their findings.^19,32 Eleven case reports present a total of 13 patients with sGD accompanied by signs and symptoms that mimic cardiac pathology including chest pain, complete heart block, sinus bradycardia, syncope, and other electrocardiogram changes suggestive of acute coronary syndrome, possibly due to a theorized but unproven cardiobiliary reflex.^33–43 Our study found that patients who experienced chest pain may interpret their symptoms as suggestive of a heart attack, driving them to seek care promptly. Regardless of whether our participants were experiencing chest pain due to the theorized cardiobiliary reflex reported only in case studies, or if they were simply interpreting their epigastric pain as located in the chest, the relationship between interpreted chest pain and gallstone disease deserves further study.

Our data suggest that diagnosis in the ED does not necessarily determine that a patient will undergo emergency CCY, as more than half of our nonemergency CCY patients received their diagnosis of sGD in the ED. Some patients with chest pain reported that they were fearful that they were suffering a heart attack or other cardiac illness, citing this fear as their primary motivator to seek care in the ED. Once evaluated in the ED, some of these patients were discharged with a diagnosis of sGD and underwent subsequent nonemergency CCY. As such, whether chest pain motivates care seeking in the emergency or the outpatient setting, patients with gallstone-associated chest pain could be less likely to undergo emergency CCYs due to their possible earlier presentation. This hypothesis is supported by our descriptive data which suggest that more patients who underwent nonemergency CCY experienced chest pain than those who underwent emergency CCY. Although presentation to the ED for chest pain may prompt diagnosis in some patients, others may be ruled out for acute cardiac pathology and be sent home without a diagnosis of sGD. Nontraumatic chest pain accounts for over 6.5 million annual ED visits, and 47%−57% of such patients are assigned a diagnostic code of “nonspecific chest pain”, depending on their age group.^44,45 This represents a sizable group of patients with chest pain of unclear etiology, many of whom may be experiencing gallstone-associated chest pain. If this hypothesis is supported by future studies, this presents an opportunity for routine inclusion of gallstone disease in the differential diagnosis for patients with chest pain which may facilitate prompt diagnosis and nonemergency surgical management.

The impact of patients’ knowledge of their family history of chronic medical illness (e.g., cancer, heart disease, diabetes) on perceived risk of disease and adoption of preventive lifestyle behaviors has been characterized.^46,47 We uncover a relationship between patients’ knowledge of their family history of gallstone disease and their symptom interpretation and care-seeking behaviors that led to removal of their gallbladder. Given the well-demonstrated heritability and high prevalence of gallstone disease, this relationship has the potential to play a role in the diagnosis and treatment of the 1 million patients who undergo CCY in the US annually.^9,17,18 This could be especially relevant in Hispanic populations, where sGD is not only more common but where genetic factors account for an estimated 45%−65% of sGD risk (versus 25%−30% in European populations).^48–50 Our interviews presented two scenarios of family history knowledge: those with prospective knowledge of gallstone disease family history and those with retrospective knowledge of gallstone disease family history. Patients with prospective knowledge of their family history were able to draw parallels between their own symptoms and that of their family members, which supported their recognition of their need to seek care. Alternatively, other patients were only made aware of their family history through discussions about their disease after surgery and were thus unable to incorporate this knowledge into their care-seeking decisions. In the present sample, emergency CCY patients reported retrospective knowledge of their family history, while nonemergency CCY patients described prospective knowledge of their family history. We hypothesize that patients with prospective knowledge of their family history of sGD are more likely to seek care early and are thus less likely to undergo emergency than nonemergency CCY. If this hypothesis is confirmed in subsequent studies, interventions aimed at increasing patient awareness of their family history may improve patients’ ability to contextualize their symptoms and seek prompt medical evaluation, potentially reducing their risk of undergoing emergency CCY.

This study is not without limitations. This is not a study designed or powered to identify associations between the above themes and likelihood of emergency versus nonemergency CCY. Instead, observed differences in interview content between emergency and nonemergency patients support hypothesis generation. Thus, our findings and themes will inform future adequately powered quantitative studies to support or refute our hypotheses. Due to the often-lengthy natural history of gallstone disease, some patients were asked to consider their symptoms, behaviors, and decision-making that occurred months or even years prior to the time of their interview. As such, recognition or memory of the early stages of their disease may have been imperfect. To minimize possible recall bias, we approached patients two weeks following their CCYs, which was often their first interaction with the health care system following their surgery. Purposive sampling to achieve similarly sized samples of patients who had emergency or nonemergency CCY may serve as a source of sampling bias. However, there were no demographic differences between our two patient samples. Although there were no demographic differences between our patient samples, our urban academic sample includes a higher proportion of Latino and Black patients as compared to the national population.⁵¹ This demographic representation is especially relevant for disparities in emergency and nonemergency cholecystectomies, as Latino and Black populations are less likely to undergo ambulatory CCY for their sGD.⁵²

This qualitative work undoubtedly represents an area of gallstone disease research ripe for future quantitative study. We have identified two specific findings that are deserving of further investigation. The first is the relationship between chest pain and sGD. Follow-up studies should examine if patients who undergo nonemergency CCY are more likely to report chest pain than those who undergo emergency CCY. The second pertains to patient knowledge of their own family history of gallstone disease. Further research will explore whether patients with prospective knowledge of their family history of gallstone disease are more likely to undergo nonemergency than emergency CCY. By conducting observational studies from our a priori hypotheses, we will work toward designing proactive patient-centered strategies upstream from acute care surgery interventions that will reduce sGD-related morbidity, mortality and health care costs.