Gallstones: Watch and wait, or intervene?

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Gallstones are common in the United States, affecting an estimated 1 in 7 adults. Fortunately, they are asymptomatic in up to 80% of cases, and current guidelines do not recommend cholecystectomy unless they cause symptoms. Laparoscopic cholecystectomy is the standard treatment for symptomatic gallstones, acute cholecystitis, and gallstone pancreatitis.


  • Abdominal pain is the primary symptom associated with gallstones.
  • Abdominal ultrasonography is the diagnostic test of choice to detect gallstones and assess for findings suggestive of acute cholecystitis and dilation of the common bile duct.
  • First-line therapy for asymptomatic gallstones is expectant management.
  • First-line therapy for symptomatic gallstones is cholecystectomy.



The prevalence of gallstones is approximately 10% to 15% of the adult US population. 1,2 Most cases are asymptomatic, as gallstones are usually discovered incidentally during routine imaging for other abdominal conditions, and only about 20% of patients with asymptomatic gallstones develop clinically significant complications. 2,3

Nevertheless, gallstones carry significant healthcare costs. In 2004, the median inpatient cost for any gallstone-related disease was $11,584, with an overall annual cost of $6.2 billion. 4,5

Laparoscopic cholecystectomy is the standard treatment for symptomatic cholelithiasis. For asymptomatic cholelithasis, the usual approach is expectant management (“watch and wait”), but prophylactic cholecystectomy may be an option in certain patients at high risk.


Gallstones can be classified into 2 main categories based on their predominant chemical composition: cholesterol or pigment.

Cholesterol gallstones

About 75% of gallstones are composed of cholesterol. 3,4 In the past, this type of stone was thought to be caused by gallbladder inflammation, bile stasis, and absorption of bile salts from damaged mucosa. However, it is now known that cholesterol gallstones are the result of biliary supersaturation caused by cholesterol hypersecretion into the gallbladder, gallbladder hypomotility, accelerated cholesterol nucleation and crystallization, and mucin gel accumulation.

Pigment gallstones

Black pigment gallstones account for 10% to 15% of all gallstones. 6 They are caused by chronic hemolysis in association with supersaturation of bile with calcium hydrogen bilirubinate, along with deposition of calcium carbonate, phosphate, and inorganic salts. 7

Brown pigment stones, accounting for 5% to 10% of all gallstones, 6 are caused by infection in the obstructed bile ducts, where bacteria that produce beta-glucuronidase, phospholipase, and slime contribute to formation of the stone. 8,9


Gallstone risk factors
Multiple risk factors are associated with the development of gallstones ( Table 1 ).

Age. After age 40, the risk increases dramatically, with an incidence 4 times higher for those ages 40 to 69 than in younger people. 10

Female sex. Women of reproductive age are 4 times more likely to develop gallstones than men, but this gap narrows after menopause. 11 The higher risk is attributed to female sex hormones, pregnancy, and oral contraceptive use. Estrogen decreases secretion of bile salts and increases secretion of cholesterol into the gallbladder, which leads to cholesterol supersaturation. Progesterone acts synergistically by causing hypomobility of the gallbladder, which in turn leads to bile stasis. 12,13

Ethnicity. The risk is higher in Mexican Americans and Native Americans than in other ethnic groups. 14

Rapid weight loss, such as after bariatric surgery, occurs from decreased caloric intake and promotes bile stasis, while lipolysis increases cholesterol mobilization and secretion into the gallbladder. This creates an environment conducive to bile supersaturation with cholesterol, leading to gallstone formation.

Chronic hemolytic disorders carry an increased risk of developing calcium bilirubinate stones due to increased excretion of bilirubin during hemolysis.

Obesity and diabetes mellitus are both attributed to insulin resistance. Obesity also increases bile stasis and cholesterol saturation.


Most patients with gallstones (cholelithiasis) experience no symptoms. Their gallstones are often discovered incidentally during imaging tests for unrelated or unexplained abdominal symptoms. Most patients with asymptomatic gallstones remain symptom-free, while about 20% develop gallstone-related symptoms. 2,3


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