Cholelithiasis

Essentials

• Identify patients whose pain is caused by gallstones and offer appropriate surgery.
• Complications are rare in asymptomatic gallstones, and surgery is not usually recommended http://www.dynamed.com/condition/gallstones#EXPECTANT_NON-OPERATIVE_MANAGEMENT.
• Acute cholecystitis and other complications of cholelithiasis (obstructive jaundice, suppurative cholangitis, empyema or gangrene of the gall bladder, enterobiliary fistula, gallstone ileus) should be treated as soon as possible after the onset of the symptoms .
• Patients with cholelithiasis often have other illnesses (e.g. peptic ulcer, gastro-oesophageal reflux disease, lactose intolerance, coeliac disease, functional dyspepsia, irritable bowel syndrome, pancreatitis or even cancer). Any symptoms suggestive of the above illnesses usually warrant endoscopic, laboratory or imaging studies before surgery.

Risk factors

• Age
• Female sex
• Hereditary disposition
• Obesity
• Past deliveries
• Diabetes
• Hypothyroidism (especially common bile duct stones)
• Diseases of the ileum
• Total parenteral nutrition
• Intense weight loss

Clinical manifestation

• Two-thirds of patients with gallstones are asymptomatic.
  • The pain often radiates into the shoulders or back. An attack is often accompanied by nausea and vomiting.
    • Biliary pain lasting more than 12 hours with accompanying fever or jaundice is indicative of acute cholecystitis or cholangitis.

Diagnosis

• Ultrasonography is the investigation of choice http://www.dynamed.com/condition/acute-cholecystitis#ABDOMINAL_ULTRASONOGRAPHY for the diagnosis of both uncomplicated (videos Cholelithiasis Cholelithiasis: Gallbladder Full of Gallstones (Ultrasonography)) and complicated cases. It detects stones in the gall bladder with over 90% sensitivity, but its sensitivity in detecting common bile duct stones is only 25%.
• Increased concentrations of ALT, ALP and bilirubin associated with an attack of pain is suggestive of bile duct stones http://www.dynamed.com/condition/choledocholithiasis#BLOOD_TESTS, although about 40-60% of ERCPs, carried out on increased liver enzymes alone, turn out to be normal.
• In addition to physical examination, CRP and liver function tests (ALT, ALP, bulirubin) are performed as well as ultrasound examination of the upper abdomen done to diagnose cholecystitis and to assess its severity. Pancreatitis Acute Pancreatitis is ruled out by determining plasma pancreatic amylase.
• Investigations in specialized care
  • MRCP (magnetic resonance cholangiopancreatography) is performed if bile duct stones are suspected.
  • CT scan may be done if the diagnosis is unclear or when suspecting complicated cholecystitis.
  • ERCP (endoscopic retrograde cholangiopancreatography) may be used both for the diagnosis and extraction of common bile duct stones.

Complications

• Acute cholecystitis: biliary pain lasting more than 12 hours, fever and increased CRP
• Acute cholangitis: high fever, pain and jaundice
• Acute pancreatitis: severe pain, increased plasma pancreatic amylase and increased values in liver function tests, history
• Carcinoma of the gall bladder
• Gallstone ileus (a large gallstone passes into the duodenum through a cholecystoduodenal fistula and obstructs the bowel). The clinical picture is typical of intestinal obstruction. Plain abdominal x-ray may show air in the bile ducts.

Treatment

• Asymptomatic gallstones need not be treated, since the surgical risk (albeit small) cancels out the theoretical prognostic benefit. Surgery should be considered in patients with immunosuppressive medication or if a totally calcified "porcelain" gall bladder is found in a relatively young and otherwise operable patient.
• Patients with repeated episodes of biliary pain should be operated on within a few months, those with severe symptoms even more urgently. Pain-triggering foods should be avoided while waiting for the operation. NSAIDs Non-Steroidal Anti-Inflammatory Drugs for Biliary Colic http://www.dynamed.com/condition/gallstones#ANALGESIA or spasmolytics are given to alleviate the colicky pain (the risk of agranulocytosis associated with metamizole should be kept in mind).
• Acute cholecystitis should be treated surgically as soon as possible after the diagnosis, preferably within 3 days but at the latest within 10 days from the onset of the symptoms http://www.dynamed.com/condition/acute-cholecystitis#TIMING_FOR_ACUTE_CHOLECYSTITIS. Elderly patients and those in poor general health should also be referred for surgical evaluation. Intravenous fluids and analgesics are given for initial treatment. An antimicrobial drug, such as intravenous cefuroxime 1.5 g three times daily, should be administered (the causative agent is usually E. coli) http://www.dynamed.com/condition/acute-cholecystitis#ANTIBIOTIC_SELECTION.
• In most cases, the operation can be done laparoscopically. Sometimes laparoscopic surgery has to be converted into open surgery during the procedure. Emergency surgery increases the risk of conversion.
• Patients with acute biliary pancreatitis must be immediately referred to hospital. Intravenous fluids and analgesics are given for initial treatment. MRCP (magnetic resonance cholangiopancreatography) is carried out to verify the presence of common bile duct stones. If an impacted stone or cholangitis is detected during the urgent (within 48 hours) ERCP, a sphincterotomy and removal of the stone is carried out. Cholecystectomy is carried either during the same hospital visit or within 2 weeks to prevent the recurrence of pancreatitis.
• After cholecystectomy, recurring or residual gall stones may be removed also by ERCP.
• A jaundiced patient must be referred to hospital for investigations and treatment within the next 24 hours.
• Carcinoma of the gall bladder is often an incidental finding during cholecystectomy. It is also occasionally diagnosed in patients with jaundice or other severe biliary symptoms. Individual decisions need to be made regarding further investigations and surgery.
• Dissolution therapy and other experimental methods have not become routine practice http://www.dynamed.com/condition/gallstones#DRUG_DISSOLUTION_THERAPY.

References

• Zafar SN, Obirieze A, Adesibikan B, et al. Optimal time for early laparoscopic cholecystectomy for acute cholecystitis. JAMA Surg 2015;150(2):129-36.[PubMed]
• Blohm M, Österberg J, Sandblom G, et al. The Sooner, the Better? The Importance of Optimal Timing of Cholecystectomy in Acute Cholecystitis: Data from the National Swedish Registry for Gallstone Surgery, GallRiks. J Gastrointest Surg 2017;21(1):33-40.[PubMed]
• Pisano M, Allievi N, Gurusamy K, et al. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg 2020;15(1):61.[PubMed]