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Gallstones: Watch and wait, or intervene?

Cleveland Clinic Journal of Medicine. 2018 April;85(4):323-331 | 10.3949/ccjm.85a.17035
April 2, 2018|Cleveland Clinic Journal of Medicine
Mounir Ibrahim, MD;Shashank Sarvepalli, MD;Gareth Morris-Stiff, MD, PhD;Maged Rizk, MD;Amit Bhatt, MD;R. Matthew Walsh, MD;Umar Hayat, MD;Ari Garber, MD, EDD;John Vargo, MD;Carol A. Burke, MD
Author and Disclosure Information

Mounir Ibrahim, MD
Digestive Disease and Surgery Institute, Cleveland Clinic

Shashank Sarvepalli, MD
Medicine Institute, Cleveland Clinic

Gareth Morris-Stiff, MD, PhD
HPB Surgery, Digestive Disease and Surgery Institute; Department of Stem Cell Biology and Regenerative Medicine, Lerner Research Institute, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Maged Rizk, MD
Digestive Disease and Surgery Institute, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Amit Bhatt, MD
Digestive Disease and Surgery Institute, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

R. Matthew Walsh, MD
Rich Family Distinguished Chair of Digestive Diseases, Chairman, Department of General Surgery, Digestive Disease Institute, Chairman, Academic Department of Surgery, Education Institute, Cleveland Clinic; Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Umar Hayat, MD
Medicine Institute, Cleveland Clinic

Ari Garber, MD, EdD
Digestive Disease and Surgery Institute, Cleveland Clinic; Clinical Instructor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

John Vargo, MD
Chairman, Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic; Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Carol A. Burke, MD
Vice Chair, Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic

Address: Carol A. Burke, MD, Department of Gastroenterology and Hepatology, Digestive Disease Institute, A30, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; burkec1@ccf.org

ABSTRACT

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.

KEY POINTS

  • 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.

CLINICAL PRESENTATION OF GALLSTONES (CHOLELITHIASIS)

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

Abdominal pain is the most common symptom. The phrase biliary colic—suggesting pain that is fluctuating in nature—appears ubiquitously in the medical literature, but it does not correctly characterize the pain associated with gallstones.

Most patients with gallstone symptoms describe a constant and often severe pain in the right upper abdomen, epigastrium, or both, often persisting for 30 to 120 minutes. Symptoms are frequently reported in the epigastrium when only visceral pain fibers are stimulated due to gallbladder distention. This is usually called midline pain; however, pain occurs in the back and right shoulder in up to 60% of patients, with involvement of somatic fibers.15,16 Gallstone pain is not relieved by change of position or passage of stool or gas.

Onset of symptoms more than an hour after eating or in the late evening or at night also  very strongly suggests biliary pain. Patients with a history of biliary pain are more likely to experience it again, with a 69% chance of developing recurrent pain within 2 years.17

GALLSTONE-RELATED COMPLICATIONS

Gallstone complications
In any year, approximately 1% to 3% of patients with gallstones experience a gallstone-related complication.18 These complications (Table 2) can occur in patients with or without symptoms. Patients without previous symptoms from gallstones have a slightly lower 10-year cumulative risk of complications—3% to 4% vs approximately 6% in patients who have had gallstone-related symptoms.19

Acute gallbladder inflammation (cholecystitis)

Gallbladder inflammation (cholecystitis) is the most common complication, occurring in up to 10% of symptomatic cases. Many patients with acute cholecystitis present with right upper quadrant pain that may be accompanied by anorexia, nausea, or vomiting. Inspiratory arrest on deep palpation of the right upper quadrant (Murphy sign) has a specificity of 79% to 96% for acute cholecystitis.20 Markers of systemic inflammation such as fever, elevated white blood cell count, and elevated C-reactive protein are highly suggestive of acute cholecystitis.20,21

Bile duct stones (choledocholithiasis)

Bile duct stones (choledocholithiasis) are detected in 3.4% to 12% of patients with gallstones.22,23 Most stones in the common bile duct migrate there from the gallbladder via the cystic duct. Less commonly, primary duct stones form in the duct due to biliary stasis. Removing the gallbladder does not completely eliminate the risk of bile duct stones, as stones can remain or recur after surgery.

Bile duct stones can obstruct the common bile duct, which disrupts normal bile flow and leads to jaundice. Other symptoms may include pruritus, right upper quadrant pain, nausea, and vomiting. Serum levels of bilirubin, aspartate aminotransferase, alanine aminotransferase (ALT), and alkaline phosphatase are usually high.24

Acute bacterial infection (cholangitis)

Acute bacterial infection of the biliary system (cholangitis) is usually associated with obstruction of the common bile duct. Common symptoms of acute cholangitis include right upper quadrant pain, fever, and jaundice (Charcot triad), and these are present in about 50% to 75% of cases.21 In severe cases, patients can develop altered mental status and septicemic shock in addition to the Charcot triad, a condition called the Reynold pentad. White blood cell counts and serum levels of C-reactive protein, bilirubin, aminotransferases, and alkaline phosphatase are usually elevated.21

Pancreatitis

Approximately 4% to 8% of patients with gallstones develop inflammation of the pancreas (pancreatitis).25 The diagnosis of acute pancreatitis requires at least 2 of the following:26,27

  • Abdominal pain (typically epigastric, often radiating to the back)
  • Amylase or lipase levels at least 3 times above the normal limit
  • Imaging findings that suggest acute pancreatitis.

Gallstone-related pancreatitis should be considered if the ALT level is greater than 150 U/mL, which has a 97% specificity for gallstone-related pancreatitis.28

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