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PATIENT STORY

A 44-year-old woman reports frequent episodes of severe pain in the mid and upper right side of her abdomen that usually occurs shortly after her evening meal and sometimes at night. She is obese, but otherwise healthy. The pain lasts for several hours and is steady and often causes vomiting. On physical examination, she complains of slight tenderness in the right upper quadrant (RUQ). An ultrasound confirms the presence of gallstones (Figure 64-1).

FIGURE 64-1

Ultrasound showing two echogenic gallstones in the gallbladder. Note the absence of echoes posterior to the gallstone, called "shadowing" (arrowheads). (Reproduced with permission from Brunicardi F, Andersen D, Billiar T, et al: Schwartz's Principles of Surgery, 9th ed. New York, NY: McGraw-Hill Education; 2010.)

INTRODUCTION

Gallstones are concretions (inorganic masses), usually composed of cholesterol, that form in the gallbladder or bile duct. They are formed by concretion (joining together of adjacent parts and hardening) or accretion (growth by addition or adherence of parts normally separated) of normal and/or abnormal bile constituents.

EPIDEMIOLOGY

  • Based on autopsy data, 20% of women and 8% of men have gallstones. Similar figures for gallstone prevalence of 16.6% in women 7.9% in men were reported in the third National Health and Nutrition Examination Survey.1 Prevalence is highest among Mexican Americans (26.7% of women and 8.9% of men) and lowest among African Americans (13.9% of women and 5.3% of men).

  • In a Swedish incidence study of 621 randomly selected individuals ages 35 to 85 years, 42 (8.3%) of the 503 subjects available at 5 years developed gallstones; this yielded an incidence for newly developed gallstones of 1.39 per 100 person years.2

  • Among pregnant women, 5% to 12% have gallstones and 20% to 30% have gallbladder sludge (thick mucous material containing cholesterol crystals and mucin thread or mucous gels). Gallbladder sludge is a possible precursor form of gallstone disease.1

  • Gallstones form in about 10%–20% of persons with rapid weight reduction through very-low-calorie dieting.1 In a follow-up study of patients undergoing bariatric surgery, 32.5% of 117 patients undergoing gastric bypass and 25.5% of 51 patients undergoing sleeve gastrectomy developed gallstones.3

  • Patients with asymptomatic gallstones have a 2% to 4% risk per year of developing symptoms during the first 5 years following diagnosis, and a 1% to 2% risk per year of developing symptoms thereafter.1 The incidence of gallstone complications is 0.1% to 0.3% and is preceded by warning signs.1

  • Gallstone disease is responsible for approximately 10,000 deaths per year in the United States. Most (7000) of these deaths are attributable to acute gallstone complications (e.g., cholecystitis, pancreatitis, cholangitis).4

  • Although gallbladder cancers most often occur in the setting of stones (91% of 34 patients with gallbladder cancer in one study),5 gallbladder cancer ...

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