Gallstones

Background

• Most gallstones in westernized countries are cholesterol stones. Cholesterol stones appear to form due to an interplay of several factors including underlying genetic predisposition, hepatic hypersecretion of cholesterol, alterations in metabolism, impaired gallbladder and gastrointestinal motility, and chronic inflammation.
• Risk factors for cholesterol gallstones include female gender, family history of gallstones, obesity, rapid or cyclic weight loss, and Native American (Pima Indian) or Scandinavian ethnicity. Cholesterol gallstones may be associated with coronary artery disease, metabolic syndrome and insulin resistance..
• A minority of gallstones are black pigment stones or brown pigment stones. Black pigment stones are related to excess bilirubin secretion in bile (as following alterations in heme metabolism), while brown stones are frequently secondary to biliary tract infections or biliary tract obstruction.
• Up to 18% of men and 25% of women have gallstones and most are asymptomatic. A small number with gallstones (about 1.5% per year) will be treated for gallstone-related complications or symptoms. While uncommon in children, there may be an increasing incidence of gallstones in children and adolescents.
• Gallstones may cause severe epigastric or right upper quadrant pain, acute cholecystitis, acute cholangitis, or gallstone pancreatitis. While gallbladder cancer is rare, gallstones are a risk factor for this malignancy.

Evaluation

• Gallstones may be seen incidentally during abdominal imaging or during evaluation for a variety of gastrointestinal symptoms (including dyspepsia), as the majority of individuals with gallstones are asymptomatic.
• Gallstone-related symptoms and complications of gallstones may include biliary colic, acute cholecystitis, ascending cholangitis and gallstone pancreatitis.
  • Biliary colic usually occurs following a meal as right upper quadrant (RUQ) abdominal pain with associated nausea and/or vomiting which gradually subsides.
  • Acute Cholecystitis usually has signs of both local inflammation (Murphy sign or right upper quadrant mass, pain, or tenderness) and systemic inflammation (fever, elevated white blood cell count, or elevated C-reactive protein).
  • Ascending cholangitis (resulting from gallstones obstructing the common bile duct) classically presents with Charcot triad of fever and chills, jaundice, and RUQ abdominal pain.
  • Gallstone pancreatitis' classic symptoms include nausea, vomiting, and epigastric pain radiating to the back.
• For patients with suspected biliary colic, rule out alternative causes of abdominal pain, such as functional dyspepsia, irritable bowel syndrome, gastroesophageal reflux, and hepatitis.
• Consider complete blood count, liver function tests, and a lipase test if active gallstone-related symptoms or complications are suspected
• Obtain an abdominal ultrasound to evaluate suspected gallstone-related complications or symptoms such as for biliary colic, ascending cholangitis, gallstone pancreatitis, or acute cholecystitis (Strong recommendation).
• For patients at intermediate risk (10%-50%) of choledocholithiasis (bile duct is dilated, liver function tests are abnormal, or age > 55 years), consider magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (Weak recommendation).

Management

• Asymptomatic gallstones can be managed expectantly. Asymptomatic gallstones are generally not an indication for cholecystectomy, unless the patient is immunosuppressed or has an increased risk for gallbladder cancer (such as gallbladder calcification, gallbladder polyps, or a specific at-risk ethnicity).
• In the case of biliary pain, provide analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs) such as diclofenac 75 mg intramuscularly (Strong recommendation). For severe symptoms, consider opioids. (Weak recommendation)
• Do not use bile acid litholysis either alone or combined with extracorporeal shock-wave lithotripsy for gallbladder stones. (Strong recommendation)
  • Oral litholysis with ursodiol (ursodeoxycholic acid) is indicated only for patients with small, radiolucent, noncalcified gallbladder stones and a functioning gallbladder who are unwilling or unable to have surgery.
  • Recurrence of gallstones after successful litholysis may occur in about 25–64% of patients within 5 years and 49–80% after 10 years.
• Perform cholecystectomy for gallstone disease leading to inflammatory complications (Strong recommendation):
  • within 24-72 hours for mild acute cholecystitis (Strong recommendation)
  • within 48 hours for mild gallstone pancreatitis (Strong recommendation)
• For biliary colic, consider cholecystectomy as early as possible, but also rule out alternative causes of abdominal discomfort and consider potential complications, since 10%-40% of post-cholecystectomy patients have persistent symptoms, and almost half of patients with symptomatic gallstones may not seek repeat medical care for symptoms. (Weak recommendation).
• Advise healthy lifestyle and food, regular physical activity and maintenance of an ideal body weight which may be helpful in preventing gallstones.
• For adults undergoing bariatric surgery or rapid weight loss, consider ursodiol for prevention of gall stones. (Weak recommendation)
• See also Acute Cholecystitis, Acute Cholangitis, Acute Pancreatitis in Adults, or Choledocholithiasis for related management.