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For further information, see CMDT Part 16-20: Cholelithiasis (Gallstones)

Key Features

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


  • 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

Clinical Findings

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




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