ADVERTISEMENT

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.

Laparoscopic surgery for symptomatic gallstones

Figure 1. Management of patients with gallstones.
Based on information in reference 48.
Figure 1. Management of patients with gallstones.
Patients with symptomatic gallstones are at high risk of biliary complications. Laparoscopic cholecystectomy is recommended for patients who can undergo surgery (Figure 1).48 Oral dissolution therapy and extracorporeal shock wave lithotripsy are available for patients who cannot undergo surgery but have good gallbladder function, small radiopaque stones, and mild symptoms. Clinical management and emergency laparoscopic cholecystectomy are recommended for large pigmented or radiopaque stones. Otherwise, clinical follow-up is recommended.

For patients experiencing acute cholecystitis, laparoscopic cholecystectomy within 72 hours is recommended.48 There were safety concerns regarding higher rates of morbidity and conversion from laparoscopic to open cholecystectomy in patients who underwent surgery before the acute cholecystitis episode had settled. However, a large meta-analysis found no significant difference between early and delayed laparoscopic cholecystectomy in bile duct injury or conversion rates.54 Further, early cholecystectomy—defined as within 1 week of symptom onset—has been found to reduce gallstone-related complications, shorten hospital stays, and lower costs.55–57 If the patient cannot undergo surgery, percutaneous cholecystotomy or novel endoscopic gallbladder drainage interventions can be used.

Figure 2. Management of patients with symptomatic bile duct stones (choledocholithiasis).
Reprinted from ASGE Standards of Practice Committee; Maple JT, Ben-Menachem T, Anderson MA, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endoscp 2010; 71:1–9 with permission from Elsevier.
Figure 2. Management of patients with symptomatic bile duct stones (choledocholithiasis).
For patients with bile duct stones. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) suggest that patients with an intermediate or high probability of developing choledocholithiasis should undergo preoperative or intraoperative evaluation of the common bile duct (Figure 2).31

Several variables predict the presence of bile duct stones in patients who have symptoms (Table 4). Based on these predictors, the ASGE classifies the probabilities as low (< 10%), intermediate (10% to 50%), and high (> 50%)31:

  • Table 4. Predictors of bile duct stones
    Low-risk patients require no further evaluation of the common bile duct
  • High-risk patients should undergo preoperative ERCP and stone extraction if needed
  • Intermediate-risk patients should undergo preoperative imaging with EUS or MRCP or intraoperative bile duct evaluation, depending on the availability, costs, and local expertise.

Patients with associated cholangitis should be given intravenous fluids and broad-spectrum antibiotics. Biliary decompression should be done as early as possible to decrease the risk of morbidity and mortality. For acute cholangitis, ERCP is the treatment of choice.25

Patients with acute gallstone pancreatitis should receive conservative management with intravenous isotonic solutions and pain control, followed by laparoscopic cholecystectomy.48

The timing of laparoscopic cholecystectomy in acute gallstone pancreatitis has been debated. Studies conducted during the era of open cholecystectomy reported similar or worse outcomes if cholecystectomy was done sooner rather than later.

However, in 1999, Uhl et al58 reported that 48 of 77 patients admitted with acute gallstone pancreatitis were able to undergo laparoscopic cholecystectomy during the same admission. Success rates were 85% (30 of 35 patients) in those with mild disease and 62% (8 of 13 patients) in those with severe disease. They concluded laparoscopic cholecystectomy could be safely performed within 7 days in patients with mild disease, whereas in severe disease at least 3 weeks should elapse because of the risk of infection.

In a randomized trial published in 2010, Aboulian et al59 reported that hospital length of stay (the primary end point) was shorter in 25 patients who underwent laparoscopic cholecystectomy early (within 48 hours of admission) than in 25 patients who underwent surgery after abdominal pain had resolved and laboratory enzymes showed a normalizing trend, 3.5 vs 5.8 days (P = .0016). Rates of perioperative complications and need for conversion to open surgery were similar between the 2 groups.

If there is associated cholangitis, patients should also be given broad-spectrum antibiotics and should undergo ERCP within 24 hours of admission.25–27

SUMMARY

Gallstones are common in US adults. Abdominal ultrasonography is the diagnostic imaging test of choice to detect gallbladder stones and assess for findings suggestive of acute cholecystitis and dilation of the common bile duct. Fortunately, most gallstones are asymptomatic and can usually be managed expectantly. In patients who have symptoms or have gallstone complications, laparoscopic cholecystectomy is the standard of care.

ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT