Cholelithiasis (Gallstones)

Essentials of Diagnosis

• Often asymptomatic

• Classic biliary pain ("episodic gallbladder pain") characterized by infrequent episodes of steady severe pain in epigastrium or right upper quadrant with radiation to right scapula

• Detected on ultrasonography

General Considerations

• Gallstones are classified according to their predominant composition

  • Cholesterol stones

  • Calcium bilirubinate stones

    • Comprise < 20% of the stones found in Europe or the United States

    • Comprise 30–40% of the stones found in Japan

Demographics

• More common in women than in men

• Incidence increases in both sexes and all races with aging

• In the United States, the prevalence of gallstones is 8.6% in women and 5.5% in men, with the highest rates in persons over age 60

• Although cholesterol gallstones are less common in black people, calcium bilirubinate cholelithiasis attributable to hemolysis occurs in over one-third of persons with sickle cell disease

• Native Americans of both the Northern and Southern Hemispheres have a high rate of cholesterol cholelithiasis, probably because of "thrifty" (LITH) genes that promote efficient calorie utilization and fat storage

• As many as 75% of Pima and other American Indian women over the age of 25 years have cholelithiasis

• Risk factors for gallstones

  • Obesity, especially in women

  • Rapid weight loss increases the risk of symptomatic gallstone formation

  • Diabetes mellitus and insulin resistance as well as a high intake of carbohydrates and hypertriglyceridemia

  • Pregnancy; also associated with increased risk of symptomatic gallbladder disease

  • Cirrhosis and hepatitis C virus infection (especially in men)

  • Certain drugs (clofibrate, octreotide, ceftriaxone)

  • Crohn disease

• Prolonged fasting (over 5–10 days) can lead to formation of biliary "sludge" (microlithiasis), which usually resolves with refeeding but can lead to gallstones or biliary symptoms

• Hormone replacement therapy conveys a slight risk for biliary tract surgery

Symptoms and Signs

• See Table 16–9

• Cholelithiasis is frequently asymptomatic and is discovered incidentally

• "Symptomatic" cholelithiasis usually means characteristic right upper quadrant or epigastric discomfort or pain (biliary pain)

• Small intestinal obstruction due to "gallstone ileus" is the initial manifestation in some patients

Differential Diagnosis

• Acute cholecystitis

• Acute pancreatitis

• Peptic ulcer disease

• Appendicitis

• Acute hepatitis

• Myocardial infarction

• Radicular pain in T6–T10 dermatome, eg, preeruptive zoster

Laboratory Tests

• Table 16–9

• Laboratory tests are normal in persons with asymptomatic gallstones

Imaging Studies

• Ultrasonography is the most sensitive imaging modality

• CT is an alternative but usually not necessary

Diagnostic Procedures

• See Cholecystitis, Acute; or Choledocholithiasis & Cholangitis

Medications

• Nonsteroidal anti-inflammatory drugs (eg, diclofenac 50–75 mg intramuscularly) can be used to relieve biliary pain

• Ursodeoxycholic acid

  • 8–13 mg/kg given orally in divided doses daily for up to 2 years, dissolves some cholesterol stones

  • May be considered in selected patients who refuse cholecystectomy

  • It is most effective in patients with a functioning gallbladder, as determined by gallbladder visualization on oral cholecystography, and multiple small "floating" gallstones (representing not more than 15% of patients with gallstones)

  • In 50% of patients, gallstones recur within 5 years after treatment is stopped

  • 500–600 mg/day reduces the risk of gallstone formation due to rapid weight loss (and diets higher in fat)

Surgery

• There is generally no need for prophylactic cholecystectomy in an asymptomatic person unless

  • The gallbladder is calcified or gallstones are over 3 cm in diameter

  • The patient is a Native American or a candidate for bariatric surgery or cardiac transplantation

• Laparoscopic cholecystectomy

  • Treatment of choice for symptomatic gallbladder disease

  • The minimal trauma to the abdominal wall makes it possible for patients to go home within 1 day after the procedure and to return to work within 7 days (instead of weeks for those undergoing standard open cholecystectomy)

  • If problems are encountered, the surgery can be converted to a conventional open cholecystectomy

  • See Choledocholithiasis & Cholangitis

• For pregnant patients

  • A conservative approach to biliary pain is advised

  • For those with repeated attacks of biliary pain or acute cholecystitis, cholecystectomy can be performed—even laparoscopically—preferably in the second trimester

Therapeutic Procedures

• Enterolithotomy alone is considered adequate treatment in most patients with gallstone ileus

• Lithotripsy in combination with bile salt therapy for single radiolucent stones < 20 mm in diameter is no longer generally used in the United States

Complications

• Cholecystectomy may increase the risk of esophageal, proximal small intestinal, and colonic adenocarcinomas as well as hepatocellular carcinoma because of increased duodenogastric reflux and changes in intestinal exposure to bile, respectively

• There may be persistence of symptoms after removal of the gallbladder (see Pre- and Post-Cholecystectomy Syndromes)

Prognosis

• Symptoms (biliary pain) develop in 10–25% of patients with gallstones over time

Prevention

• Diet

  • Low-carbohydrate

  • Mediterranean

  • Low-fat

  • High-fiber

• Physical activity

• Consumption of caffeinated coffee appears to protect against gallstones in women

When to Refer

• Patients should be referred when they require surgery