Surgical and Nonsurgical Management of Gallstones


FREE PREVIEW. AAFP members and paid subscribers: Log in to get free access. All others: Purchase online access.


FREE PREVIEW. Purchase online access to read the full version of this article.

Am Fam Physician. 2014 May 15;89(10):795-802.

  Patient information: See related handout on gallstones, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Cholelithiasis, or gallstones, is one of the most common and costly of all the gastrointestinal diseases. The incidence of gallstones increases with age. At-risk populations include persons with diabetes mellitus, persons who are obese, women, rapid weight cyclers, and patients on hormone therapy or taking oral contraceptives. Most patients are asymptomatic; gallstones are discovered incidentally during ultrasonography or other imaging of the abdomen. Asymptomatic patients have a low annual rate of developing symptoms (about 2% per year). Once symptoms appear, the usual presentation of uncomplicated gallstones is biliary colic, caused by the intermittent obstruction of the cystic duct by a stone. The pain is characteristically steady, is usually moderate to severe in intensity, is located in the epigastrium or right upper quadrant of the abdomen, lasts one to five hours, and gradually subsides. If pain persists with the onset of fever or high white blood cell count, it should raise suspicion for complications such as acute cholecystitis, gallstone pancreatitis, and ascending cholangitis. Ultrasonography is the best initial imaging study for most patients, although additional imaging studies may be indicated. The management of acute biliary colic mainly involves pain control with nonsteroidal anti-inflammatory drugs or narcotic pain relievers. Oral dissolution therapy is usually minimally successful and used only if the patient cannot undergo surgery. Laparoscopic cholecystectomy remains the surgical choice for symptomatic and complicated gallstones, with a shorter hospital stay and shorter convalescence period than open cholecystectomy. Percutaneous cholecystostomy is an alternative for patients who are critically ill with gallbladder empyema and sepsis.

Cholelithiasis, or gallstones, is one of the most common and costly of all the gastrointestinal diseases.1 Gallstones are solid calculi formed by precipitation of supersaturated bile composed of cholesterol monohydrate crystals or by “black pigment” of polymerized calcium bilirubinate.2 In the United States, more than 80% of gallstones contain cholesterol as their major component. Over the past two decades, much has been learned about the epidemiology of this condition and its risk factors2  (Table 13). Gallstones are associated with high-calorie diets, type 2 diabetes mellitus, dyslipidemia, hyperinsulinism, obesity, and metabolic syndrome.2

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Ultrasonography is an appropriate initial imaging study in persons with suspected gallstones or complications of gallstones.

C

14

Expectant management is the best approach for patients with incidentally detected, asymptomatic gallstones.

B

4, 26, 27

Laparoscopic cholecystectomy remains the standard treatment for gallstones.

A

34

Antibiotic prophylaxis is not required in low-risk patients undergoing elective laparoscopic cholecystectomy.

A

38, 39

When indicated, laparoscopic cholecystectomy can be safely performed during any trimester of pregnancy.

C

47


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Ultrasonography is an appropriate initial imaging study in persons with suspected gallstones or complications of gallstones.

C

14

Expectant management is the best approach for patients with incidentally detected, asymptomatic gallstones.

B

4, 26, 27

Laparoscopic cholecystectomy remains the standard treatment for gallstones.

A

34

Antibiotic prophylaxis is not required in low-risk patients undergoing elective laparoscopic cholecystectomy.

A

38, 39

When indicated, laparoscopic cholecystectomy can be safely performed during any trimester of pregnancy.

C

47


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Table

Table 1.

Risk Factors for Gallstones

Demographics

Family history, female sex, increasing age, specific races (e.g., Chilean Indians, Mexican Americans, Pima Indians)

Dietary

Diet high in calories and refined carbohydrates, low in fiber and unsaturated fats; total parenteral nutrition

Lifestyle

Low-grade physical activity, pregnancy and multiparity, prolonged fasting, rapid weight loss

Associated conditions

Alcoholic cirrhosis, bariatric surgery, diabetes mellitus, dyslipidemia, estrogen therapy or use of oral contraceptives, gallbladder or intestinal stasis, hyperinsulinism, metabolic syndrome, obesity*


*—Obesity defined as body mass index greater than 30 kg per m2.

Adapted from Portincasa P, Moschetta A, Palasciano G. Cholesterol gallstone disease. Lancet. Copyright 2006;368(9531):234, with permission from Elsevier.

Table 1.

Risk Factors for Gallstones

Demographics

Family history, female sex, increasing age, specific races (e.g., Chilean Indians, Mexican Americans, Pima Indians)

Dietary

Diet high in calories and refined carbohydrates, low in fiber and unsaturated fats; total parenteral nutrition

Lifestyle

Low-grade physical activity, pregnancy and multiparity, prolonged fasting, rapid weight loss

Associated conditions

Alcoholic cirrhosis, bariatric surgery, diabetes mellitus, dyslipidemia, estrogen therapy or use of oral contraceptives, gallbladder or intestinal stasis, hyperinsulinism, metabolic syndrome, obesity*


*—Obesity defined as body mass index greater than 30 kg per m2.

Adapted from Portincasa P, Moschetta A, Palasciano G. Cholesterol gallstone disease. Lancet. Copyright 2006;368(9531):234, with permission from Elsevier.

Diagnosis

Gallstones are often discovered incidentally during ultrasonography or computed tomography of the abdomen. Only 10% to 20% of asymptomatic patients will eventually become symptomatic within five to 20 years of diagnosis. The average rate at which patients develop symptomatic gallstones is low, approximately 2% per year.2,4

History and Physical Examination

Patients typically present with biliary colic, described as acute onset of pain in the right upper quadrant of the abdomen or epigastrium (dermatomes T8/9) caused by brief impaction of the gallstone in the neck of the gallbladder. The pain is characteristically steady and is usually moderate to severe in intensity. It typically starts abruptly without fluctuations, is not relieved with a bowel movement, and reaches a peak within one hour. The pain tends to resolve gradually over one to five hours as the stone dislodges; if it lasts longer, suspicion for complications should be raised. More than 90% of patients presenting with a first episode of biliary colic have recurrent pain within 10 years (two-thirds of those within two years).2,3

After an episode, physical examination findings are usually normal, with the possible exception of residual upper abdominal tenderness.3  Table 2 summarizes the accuracy of clinical examination findings in patients with suspected gallstones or acute cholecystitis.5,6

View/Print Table

Table 2.

Accuracy of Clinical Findings for the Diagnosis of Gallstones and Acute Cholecystitis

Clinical findingPositive likelihood ratioNegative likelihood ratioSensitivity (%)Specificity (%)

Gallstones

Biliary colic

3.6

0.84

21

94

Radiating pain

1.6

0.62

62

61

Use of analgesics

1.6

0.38

80

51

Fat intolerance

1.3

0.83

43

68

Tenderness of upper abdomen

1.3

0.73

62

53

Food intolerance

1.2

0.86

51

57

Upper abdominal pain

1.2

0.74

68

43

Acute cholecystitis

Murphy sign* (general population)

5.0

0.4

65

87

Chills

2.6

0.9

13

95

Right upper quadrant pain

2.5

0.28

81

67

Murphy sign* (older patient)

2.3

0.66

48

79

Palpable gallbladder

2.0

0.99

2

99

Fever

1.8

0.81

35

80

Right upper quadrant tenderness

1.7

0.43

77

54


*—Inspiratory arrest during deep right upper quadrant palpation.

Information from references 5 and 6.

Table 2.

Accuracy of Clinical Findings for the Diagnosis of Gallstones and Acute Cholecystitis

Clinical findingPositive likelihood ratioNegative likelihood ratioSensitivity (%)Specificity (%)

Gallstones

Biliary colic

3.6

0.84

21

94

Radiating pain

1.6

0.62

62

61

Use of analgesics

1.6

0.38

80

51

Fat intolerance

1.3

0.83

43

68

Tenderness of upper abdomen

1.3

0.73

62

53

Food intolerance

1.2

0.86

51

57

Upper abdominal pain

1.2

0.74

68

43

Acute cholecystitis

Murphy sign* (general population)

5.0

0.4

65

87

Chills

2.6

0.9

13

95

Right upper quadrant pain

2.5

0.28

81

67

Murphy sign* (older patient)

2.3

0.66

48

79

Palpable gallbladder

2.0

0.99

2

99

Fever

1.8

0.81

35

80

Right upper quadrant tenderness

1.7

0.43

77

54


*—Inspiratory arrest during deep right upper quadrant palpation.

Information from references 5 and 6.

COMPLICATIONS

Patients with gallstones are often seen for complications; the signs and symptoms are summarized in Table 3.79 Acute cholecystitis is an inflammation of the gallbladder caused by gallstones blocking the cystic duct. It should be suspected in patients with fever, leukocytosis, right upper quadrant mass, persistent pain, a mild elevation of bilirubin levels, or Murphy sign (inspiratory arrest during deep right upper quadrant palpation). It generally follows food intake and often occurs in patients with prior attacks of biliary colic.7

View/Print Table

Table 3.

Complications of Gallstones

DiagnosisPain site and character of painRecommended diagnostic testsLaboratory tests

Acute cholecystitis

Right upper quadrant pain that is steady and lasts longer than six hours, right upper quadrant tenderness, fever, chills, and Murphy sign*

Ultrasonography or hepatobiliary iminodiacetic acid scan; computed tomography if complications suspected

Elevated white blood cell level may be present

Obstructive cholangitis secondary to choledocholithiasis

Right upper quadrant pain, exquisitely tender right upper quadrant, fever, jaundice

Endoscopic retrograde cholangiopancreatography

Leukocytosis, elevated liver enzyme levels

Gallstone pancreatitis

Epigastric pain, diffuse and constant

Endoscopic retrograde cholangiopancreatography

Elevated amylase and lipase levels


*—Inspiratory arrest during deep right upper quadrant palpation.

Information from references 7 through 9.

Table 3.

Complications of Gallstones

DiagnosisPain site and character of painRecommended diagnostic testsLaboratory tests

Acute cholecystitis

Right upper quadrant pain that is steady and lasts longer than six hours, right upper quadrant tenderness, fever, chills, and Murphy sign*

Ultrasonography or hepatobiliary iminodiacetic acid scan; computed tomography if complications suspected

Elevated white blood cell level may be present

Obstructive cholangitis secondary to choledocholithiasis

Right upper quadrant pain, exquisitely tender right upper quadrant, fever, jaundice

Endoscopic retrograde cholangiopancreatography

Leukocytosis, elevated liver enzyme levels

Gallstone pancreatitis

Epigastric pain, diffuse and constant

Endoscopic retrograde cholangiopancreatography

Elevated amylase and lipase levels


*—Inspiratory arrest during deep right upper quadrant palpation.

Information from references 7 through 9.

Choledocholithiasis refers to gallstones that have migrated from the gallbladder into the common bile duct, most often via the cystic duct. Common duct stones can be asymptomatic or can lead to complications such as gallstone pancreatitis or acute cholangitis. Ascending cholangitis is characterized by fever, jaundice, and abdominal pain (Charcot triad); the addition of altered mentation and hypotension is known as Reynolds pentad. Both develop as a result of stasis of bile and bacterial infection in the biliary tract, and should be promptly addressed with intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) to clear the duct.8,10,11

Patients with gallstone pancreatitis, caused by obstruction at the level of the sphincter of Oddi, typically present with epigastric pain and increased amylase and lipase levels.9,11

Diagnostic Testing

IMAGING STUDIES

Table 4 summarizes the tests used to diagnose gallstones.1222 The recommended initial imaging study for most patients with suspected gallstones or a complication of gallstones is abdominal ultrasonography. It is inexpensive, has no associated radiation exposure, and is highly sensitive for detection of gallstones.1214 Computed tomography should be considered in patients with negative or equivocal ultrasonography results or if complications of gallstones are suspected.13,14

View/Print Table

Table 4.

Diagnostic Studies for Gallstones and Complications of Gallstones

Diagnostic studyAccuracyComment

Ultrasonography

High specificity (> 98%) and sensitivity (> 95%) for identifying gallstones; false-negative rate of 1% to 4%

Inexpensive; noninvasive; first-line test for patients with suspected gallstones or acute cholecystitis; provides anatomic information, such as presence of polyps, common bile duct diameter, and parenchymal hepatic abnormalities

Hepatobiliary iminodiacetic acid scan

High sensitivity (97%) and specificity (77%) for the diagnosis of acute cholecystitis; normal findings virtually rule out acute cholecystitis

Useful to visualize the biliary tree and to assess liver and gallbladder function; can diagnose or rule out biliary dyskinesia

Hepatobiliary iminodiacetic acid is normally taken up by the liver and excreted into bile, where it fills the gallbladder and can be detected with a gamma camera; failure of hepatobiliary iminodiacetic acid to fill the gallbladder at two hours after injection is indicative of cystic duct obstruction

Magnetic resonance cholangiopancreatography

High sensitivity (97%) and specificity (98%) for identifying gallstones

Noninvasive; can identify gallstones anywhere in the biliary tract

Reserved for cases in which choledocholithiasis is suspected

Computed tomography

Sensitivity of 79% and specificity of 100% for identifying gallstones

Superior to ultrasonography in visualizing the biliary tree and distal common bile duct, but higher cost and radiation exposure make it a second-line option to ultrasonography

Endoscopic retrograde cholangiopancreatography

Sensitivity of 85% to 87% and specificity of 100% for determining normal biliary system, bile duct obstruction, and choledocholithiasis

In studies was 94% effective for stone removal

Diagnostic and therapeutic; usually performed in conjunction with endoscopic retrograde sphincterotomy and gallstone extraction

Plain abdominal radiography

Useful for excluding other causes of acute abdominal pain (e.g., intestinal obstruction, visceral perforation, renal stones, chronic calcific pancreatitis)


NOTE: Studies are listed in order of preference.

Information from references 12 through 22.

Table 4.

Diagnostic Studies for Gallstones and Complications of Gallstones

Diagnostic studyAccuracyComment

Ultrasonography

High specificity (> 98%) and sensitivity (> 95%) for identifying gallstones; false-negative rate of 1% to 4%

Inexpensive; noninvasive; first-line test for patients with suspected gallstones or acute cholecystitis; provides anatomic information, such as presence of polyps, common bile duct diameter, and parenchymal hepatic abnormalities

Hepatobiliary iminodiacetic acid scan

High sensitivity (97%) and specificity (77%) for the diagnosis of acute cholecystitis; normal findings virtually rule out acute cholecystitis

Useful to visualize the biliary tree and to assess liver and gallbladder function; can diagnose or rule out biliary dyskinesia

Hepatobiliary iminodiacetic acid is normally taken up by the liver and excreted into bile, where it fills the gallbladder and can be detected with a gamma camera; failure of hepatobiliary iminodiacetic acid to fill the gallbladder at two hours after injection is indicative of cystic duct obstruction

Magnetic resonance cholangiopancreatography

High sensitivity (97%) and specificity (98%) for identifying gallstones

Noninvasive; can identify gallstones anywhere in the biliary tract

Reserved for cases in which choledocholithiasis is suspected

Computed tomography

Sensitivity of 79% and specificity of 100% for identifying gallstones

Superior to ultrasonography in visualizing the biliary tree and distal common bile duct, but higher cost and radiation exposure make it a second-line option to ultrasonography

Endoscopic retrograde cholangiopancreatography

Sensitivity of 85% to 87% and specificity of 100% for determining normal biliary system, bile duct obstruction, and choledocholithiasis

In studies was 94% effective for stone removal

Diagnostic and therapeutic; usually performed in conjunction with endoscopic retrograde sphincterotomy and gallstone extraction

Plain abdominal radiography

Useful for excluding other causes of acute abdominal pain (e.g., intestinal obstruction, visceral perforation, renal stones, chronic calcific pancreatitis)


NOTE: Studies are listed in order of preference.

Information from references 12 through 22.

A hepatobiliary iminodiacetic acid (HIDA) scan is a functional study that evaluates for cystic duct obstruction. It is useful for the diagnosis of acute cholecystitis. Normal gallbladder visualization excludes acute cholecystitis with an accuracy of 99%.12 A variant of the study, known as a cholecystokinin-HIDA scan, can be used in the elective setting to assess gallbladder contractility and calculate an ejection fraction. A cholecystokinin-HIDA scan is helpful in patients with suspected gallstones, but who have normal findings on ultrasonography and workup for their symptoms (e.g., upper endoscopy, upper gastrointestinal series, negative Helicobacter pylori serology).

Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive study with high sensitivity and specificity for the detection of gallstones. According to the 2010 American College of Radiology guidelines, magnetic resonance imaging is recommended as a secondary imaging study if ultrasonography does not result in a clear diagnosis of acute cholecystitis or gallstones.14

Choledocholithiasis is found in 6% to 12% of patients with gallstones; it increases the risk of recurrent symptoms, pancreatitis, and cholangitis.13 It should be suspected in any patient with a common bile duct stone on ultrasonography, symptoms of ascending cholangitis, a bilirubin level higher than 4 mg per dL (68.4 μmol per L), or dilated common bile duct (greater than 6 mm) on ultrasonography.8 The presence of any of the previously mentioned signs or symptoms warrants additional biliary imaging; options include MRCP, endoscopic ultrasonography, or preoperative ERCP.23 Endoscopic ultrasonography has accuracy similar to MRCP, but is more invasive.13 ERCP is invasive, with 4% to 10% of patients experiencing hemorrhage, acute pancreatitis, acute cholangitis, or perforation.24 An advantage of ERCP is in its potentially therapeutic nature, enabling stone extraction, placement of stents, and biopsy of any diagnosed lesion that might become evident during the study.25

LABORATORY STUDIES

Laboratory studies recommended for patients with suspected complications of gallstones include a complete blood count and measurement of hepatic transaminase, total bilirubin, alkaline phosphatase, amylase, and lipase levels. Although patients with acute cholecystitis often have mild leukocytosis, the absence of leukocytosis does not exclude this diagnosis. Abnormal findings on liver function testing also occur in patients with cholecystitis, as well as in patients with cholangitis. Elevated amylase and lipase levels, or abnormal findings on liver function testing raise suspicion for gallstone pancreatitis. A high white blood cell count may indicate a gangrenous or perforated gallbladder, or the presence of other pathology.11,13

Treatment

Although the natural history of gallstones is generally benign, the physician must decide whether treatment is needed. When considering gallstones, it is helpful to categorize patients into the following groups: those with incidentally detected, asymptomatic gallstones; with symptomatic gallstones; with atypical symptoms and gallstones on imaging; and with typical symptoms but no gallstones on imaging. A suggested approach to the management of gallstones is shown in Figure 1.4

View/Print Figure

Management of Gallstones

Figure 1.

Algorithm for the suggested approach to management of gallstones. (ERCP = endoscopic retrograde cholangiopancreatography; LC = laparoscopic cholecystectomy.)

Adapted with permission from Portincasa P, Ciaula AD, Bonfrate L, Wang DQ. Therapy of gallstone disease: what it was, what it is, what it will be. World J Gastrointest Pharmacol Ther. 2012;3(2):9.

Management of Gallstones


Figure 1.

Algorithm for the suggested approach to management of gallstones. (ERCP = endoscopic retrograde cholangiopancreatography; LC = laparoscopic cholecystectomy.)

Adapted with permission from Portincasa P, Ciaula AD, Bonfrate L, Wang DQ. Therapy of gallstone disease: what it was, what it is, what it will be. World J Gastrointest Pharmacol Ther. 2012;3(2):9.

Expectant management is the best approach for patients with incidentally detected, asymptomatic gallstones.4,26,27  However, even in these patients, cholecystectomy may be indicated in certain circumstances, such as in patients planning to have a transplant and patients with hemolytic anemia (Table 5).4,2830

View/Print Table

Table 5.

Exceptions to Expectant Management in Persons with Asymptomatic Gallstones

Patient populationComment

Calcification of the gallbladder (porcelain gallbladder)

High risk of gallbladder cancer

Hemolytic anemia (e.g., sickle cell disease)

High risk of forming calcium bilirubinate gallstones because of chronic hemolysis; may become symptomatic, with recurrent episodes of abdominal pain

Large gallstones (greater than 3 cm)

Higher risk of gallbladder cancer

Morbidly obese undergoing bariatric surgery

High risk of becoming symptomatic during rapid weight loss

Native Americans

Higher risk of gallbladder cancer compared with general population

Planning to have a transplant

Immunosuppressive therapy mutes symptoms and blunts the ability to fight a septic infection; cholecystectomy is a consideration in this subgroup

Small gallstones and gallbladder dysmotility

Higher risk of pancreatitis


Information from references 4, and 28 through 30.

Table 5.

Exceptions to Expectant Management in Persons with Asymptomatic Gallstones

Patient populationComment

Calcification of the gallbladder (porcelain gallbladder)

High risk of gallbladder cancer

Hemolytic anemia (e.g., sickle cell disease)

High risk of forming calcium bilirubinate gallstones because of chronic hemolysis; may become symptomatic, with recurrent episodes of abdominal pain

Large gallstones (greater than 3 cm)

Higher risk of gallbladder cancer

Morbidly obese undergoing bariatric surgery

High risk of becoming symptomatic during rapid weight loss

Native Americans

Higher risk of gallbladder cancer compared with general population

Planning to have a transplant

Immunosuppressive therapy mutes symptoms and blunts the ability to fight a septic infection; cholecystectomy is a consideration in this subgroup

Small gallstones and gallbladder dysmotility

Higher risk of pancreatitis


Information from references 4, and 28 through 30.

Prophylactic treatment, usually with laparoscopic cholecystectomy, should be recommended for patients with biliary-type symptoms or those with complications of gallstones, because these patients are likely to have recurrent and more severe symptoms.

For patients with gallstones on imaging but atypical symptoms, other common gastrointestinal diagnoses should be considered, such as peptic ulcer disease, gastroesophageal reflux disease, or irritable bowel syndrome.

Finally, for patients presenting with symptoms highly suggestive of gallstones but without gallstones on imaging, a cholecystokinin-HIDA scan should be considered. In up to 20% of the patients with symptoms typical of biliary colic, no gallstones are seen on imaging, possibly because of small size or stone composition.3 Although such patients may be treated expectantly, studies indicate that laparoscopic cholecystectomy may be beneficial in those with long-standing symptoms of biliary-type colic in the absence of identified gallstones who have a reduced gallbladder ejection fraction and reproducible symptoms with the injection of cholecystokinin.31

PAIN CONTROL

Treatment of acute biliary colic primarily involves pain control with nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotic pain relievers.

NSAIDs are preferred for most patients because they are equally effective with fewer adverse effects. A randomized controlled trial of 324 patients given intravenous ketorolac or meperidine (Demerol) found that both medications were similarly effective at relieving pain, but that patients receiving an NSAID had fewer adverse effects.32

Another option for pain control is antispasmodic agents (e.g., scopolamine), which are thought to relax and relieve the spasms of the gallbladder. However, comparison studies have shown that NSAIDs provide faster and more effective pain relief.33 The patient should fast as part of the conservative management of biliary colic and to avoid the release of endogenous cholecystokinin.

SURGICAL TREATMENT

Patients with symptomatic gallstones can be divided into two categories: those who have simple biliary colic and those with complications. Cholecystectomy, usually laparoscopic, is recommended for most patients with symptomatic gallstones.34 However, expectant management is also a valid alternative. For example, in one study of 69 adults with symptomatic gallstones treated expectantly, only 35 required cholecystectomy after a median follow-up of 5.6 years.27

In a Cochrane review of laparoscopic cholecystectomy vs. open cholecystectomy, laparoscopic surgery was similar to the open procedure in complication rates and surgical time, but resulted in a shorter hospital stay (three fewer days; 95% confidence interval, 2.3 to 3.9 days) and shorter convalescence period (22 fewer days; 95% confidence interval, 8 to 37 days).34

Laparoscopic cholecystectomy is the most commonly performed abdominal surgery in industrialized countries, with almost 900,000 procedures performed annually in Europe and the United States.34,35 The rate of conversions to laparotomy for uninflamed gallbladder disease ranges from 2% to 15%, and in cases of acute cholecystitis, from 6% to 35%.35 Factors that increase the risk of conversion to open cholecystectomy include male sex, age 60 years or older, previous upper abdominal surgery, thickened gallbladder wall on ultrasonography, and acute cholecystitis.36,37  Table 6 provides the indications and contraindications for laparoscopic cholecystectomy.35

View/Print Table

Table 6.

Indications and Contraindications for Laparoscopic Cholecystectomy

Indications

Acute cholecystitis, biliary dyskinesia, complications related to common bile duct stones, gallstones (symptomatic or asymptomatic [Table 5])

Contraindications

Absolute: gallbladder cancer, inability to tolerate general anesthesia, uncontrolled coagulopathy

Relative*: advanced cirrhosis/liver failure, coagulopathy, peritonitis, previous upper abdominal surgeries, septic shock, severe acute peritonitis


*—May require special care and preparation of the patient and careful assessment of risks vs. benefits.

Information from reference 35.

Table 6.

Indications and Contraindications for Laparoscopic Cholecystectomy

Indications

Acute cholecystitis, biliary dyskinesia, complications related to common bile duct stones, gallstones (symptomatic or asymptomatic [Table 5])

Contraindications

Absolute: gallbladder cancer, inability to tolerate general anesthesia, uncontrolled coagulopathy

Relative*: advanced cirrhosis/liver failure, coagulopathy, peritonitis, previous upper abdominal surgeries, septic shock, severe acute peritonitis


*—May require special care and preparation of the patient and careful assessment of risks vs. benefits.

Information from reference 35.

Antibiotic prophylaxis is not required in low-risk patients undergoing elective laparoscopic cholecystectomy, but it may reduce the incidence of wound infection in high-risk patients (i.e., those older than 60 years; patients with diabetes mellitus, acute colic within 30 days of surgery, jaundice, acute cholecystitis, or cholangitis).38,39 Antibiotic prophylaxis should be limited to a single preoperative dose of intravenous cefazolin, 1 g given within one hour of skin excision.40

ORAL DISSOLUTION THERAPY

For asymptomatic pigmented or calcified gallstones, no medical therapy aside from pain control is recommended. For cholesterol-containing gallstones, litholysis with oral agents is a historical option that is less often used in today's clinical practice. Symptomatic patients who are not candidates for surgery or those who have small gallstones (5 mm or smaller) in a functioning gallbladder with a patent cystic duct are candidates for dissolution therapy. Options include oral ursodeoxycholic acid (ursodiol [Actigall]) and chenodeoxycholic acid.4,41 Both agents decrease hepatic secretion of biliary cholesterol, cause formation of unsaturated bile, and promote dissolution of cholesterol crystals and gallstones. After six to 12 months of therapy, it may eventually result in dissolution of small gallstones, but with a recurrence rate of more than 50%. Oral dissolution has several disadvantages, including the lengthy time frame of observation (up to two years). Fewer than 10% of patients with symptomatic gallstones are candidates for this therapy.4,41

EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY

When surgery is to be avoided, extracorporeal shock wave lithotripsy is a noninvasive therapeutic alternative for symptomatic patients. Although serious adverse effects (e.g., biliary pancreatitis, liver hematoma) are rare, limitations of the procedure include stone recurrence. Also, complete ductal clearance is not always achieved because of the size or position of the stones.42 However, recent studies demonstrated usefulness of extracorporeal shock wave lithotripsy for large pancreatic and common bile duct stones followed by ERCP, with results comparable to those of surgery with regard to pain relief and duct clearance.43

NEW SURGICAL TECHNIQUES

As laparoscopic techniques evolve, physicians continue to try to make surgery as minimally invasive as possible. One such procedure is called single incision laparoscopic surgery, totally transumbilical single-port surgery, laparoendoscopic single-site surgery, or single incision multiport laparoendoscopic surgery. A 2013 systematic review comparing single incision laparoscopic surgery with standard laparoscopic cholecystectomy found no advantage with single incision laparoscopic surgery and concluded that such a procedure cannot be routinely recommended outside of clinical trials.44

The second type of procedure is called natural orifice transluminal endoscopic surgery, an approach that makes use of one of the body's existing orifices for abdominal access. In the case of cholecystectomy, the most common access is transvaginal. This procedure is currently hampered by the unavailability of suitable instrumentation.45 Studies are currently underway and long-term outcomes are forthcoming.

Special Populations

PREGNANCY

In pregnant women with symptomatic gallstones, the initial management is supportive care, which is usually successful.46 Because NSAIDs are generally not recommended in pregnancy, pain control can be achieved with intravenous administration of meperidine. Ursodeoxycholic acid has been administered in pregnant patients to manage intrahepatic cholestasis, but the safety and effectiveness of treating gallstones during pregnancy have not been evaluated (U.S. Food and Drug Administration pregnancy category B). Chenodeoxycholic acid should not be used in pregnant patients (U.S. Food and Drug Administration pregnancy category X). Surgery is usually reserved for patients with recurrent or intractable biliary pain or those who have complications related to gallstones. When surgery is indicated, the laparoscopic approach is preferred, and has been used safely in all trimesters.47

OLDER AND CRITICALLY ILL PATIENTS

The clinical presentation of gallstones in older patients may be different because of impaired cognition and the presence of comorbidities. A history of biliary colic might be difficult to obtain, and in patients with acute cholecystitis, fever and Murphy sign are often absent.48 Although surgery is the treatment of choice for acute cholecystitis, it is associated with increased mortality in older persons.49

In patients who are critically ill with gallbladder empyema and sepsis, cholecystectomy can be life threatening. In this circumstance, the surgeon may elect to perform percutaneous cholecystostomy, which involves placement of a percutaneous-transhepatic-cholecystostomy tube using computed tomography or ultrasonography guidance, with delayed interval cholecystectomy. Once the patient's condition is more stable, definitive cholecystectomy can be performed.50,51

PATIENTS WITH CIRRHOSIS

Because of gallbladder dysfunction and increased hemolysis, patients with cirrhosis have a higher rate of gallstones than the general population. These patients also present significant surgical challenges with risk of liver failure and significant bleeding in the face of portal hypertension. Laparoscopic cholecystectomy is the procedure of choice for those with Child-Pugh class A and B cirrhosis.52

Data Sources: A search of the Cochrane database, PubMed, DARE, and National Guideline Clearinghouse was performed using the key terms gallstones, cholelithiasis, laparoscopic cholecystectomy, cholelithiasis and hepatic cirrhosis, and pregnancy and cholelithiasis. Search dates: December 1 through 20, 2010, and March through April 2014.

The Authors

show all author info

SHERLY ABRAHAM, MD, is the director of the Family Medicine Residency Program at The Brooklyn (NY) Hospital Center....

HAIDY G. RIVERO, MD, is a junior attending at The Brooklyn Hospital Center.

IRINA V. ERLIKH, MD, is an associate director in the Family Medicine Residency Program at The Brooklyn Hospital Center.

LARRY F. GRIFFITH, MD, is an associate director in the Department of Surgery Residency Program at The Brooklyn Hospital Center.

VASANTHA K. KONDAMUDI, MD, is the chair of family medicine and chief quality officer in the Department of Family Medicine at The Brooklyn Hospital Center.

Author disclosure: No relevant financial affiliations.

Address correspondence to Sherly Abraham, MD, The Brooklyn Hospital Center, 121 Dekalb Ave., Brooklyn, NY 11201 (e-mail: sha9035@nyp.org). Reprints are not available from the authors.

REFERENCES

show all references

1. Lammert F, Sauerbruch T. Mechanisms of disease: the genetic epidemiology of gallbladder stones. Nat Clin Pract Gastroenterol Hepatol. 2005;2(9):423–433....

2. Wittenburg H. Hereditary liver disease: gallstones. Best Pract Res Clin Gastroenterol. 2010;24(5):747–756.

3. Portincasa P, Moschetta A, Palasciano G. Cholesterol gallstone disease. Lancet. 2006;368(9531):230–239.

4. Portincasa P, Ciaula AD, Bonfrate L, Wang DQ. Therapy of gallstone disease: what it was, what it is, what it will be. World J Gastrointest Pharmacol Ther. 2012;3(2):7–20.

5. Berger MY, van der Velden JJ, Lijmer JG, de Kort H, Prins A, Bohnen AM. Abdominal symptoms: do they predict gallstones? A systematic review. Scand J Gastroenterol. 2000;35(1):70–76.

6. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis? [published correction appears in JAMA. 2009; 302(7):739]. JAMA. 2003;289(1):80–86.

7. Singer AJ, McCracken G, Henry MC, Thode HC Jr, Cabahug CJ. Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med. 1996;28(3):267–272.

8. Rosh AJ, Manko JA, Santen S. Cholangitis in emergency medicine. http://emedicine.medscape.com/article/774245-overview. Accessed January 14, 2014.

9. Gardner TB, Berk BS. Acute pancreatitis. http://emedicine.medscape.com/article/181364-overview. Accessed January 14, 2014.

10. Yang MH, Chen TH, Wang SE, et al. Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy. Surg Endosc. 2008;22(7):1620–1624.

11. Bellows CF, Berger DH, Crass RA. Management of gallstones. Am Fam Physician. 2005;72(4):637–642.

12. Brunetti JC. Cholelithiasis imaging. http://emedicine.medscape.com/article/366246-overview#a23. Accessed January 14, 2014.

13. Heuman DM, Mihas AA, Allen J. Cholelithiasis. http://emedicine.medscape.com/article/175667-overview. Accessed January 14, 2014.

14. American College of Radiology. ACR Appropriateness Criteria: right upper quadrant pain. http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RightUpperQuadrantPain.pdf. Accessed January 14, 2014.

15. Schirmer BD, Winters KL, Edlich RF. Cholelithiasis and cholecystitis. J Long Term Eff Med Implants. 2005;15(3):329–338.

16. Bahram M, Gaballa G. The value of pre-operative magnetic resonance cholangiopancreatography (MRCP) in management of patients with gall stones. Int J Surg. 2010;8(5):342–345.

17. Chang JH, Lee IS, Lim YS, et al. Role of magnetic resonance cholangiopancreatography for choledocholithiasis: analysis of patients with negative MRCP. Scand J Gastroenterol. 2012;47(2):217–224.

18. Guarise A, Baltieri S, Mainardi P, Faccioli N. Diagnostic accuracy of MRCP in choledocholithiasis. Radiol Med. 2005;109(3):239–251.

19. Barakos JA, Ralls PW, Lapin SA, et al. Cholelithiasis: evaluation with CT. Radiology. 1987;162(2):415–418.

20. Brown LM, Rogers SJ, Cello JP, Brasel KJ, Inadomi JM. Cost-effective treatment of patients with symptomatic cholelithiasis and possible common bile duct stones. J Am Coll Surg. 2011;212(6):1049–1060.e1-e7.

21. Pressacco J, Reinhold C, Barkun AN, Barkun JS, Valois E, Joseph L. Accuracy of MRCP vs. ERCP in the evaluation of patients with bile duct obstruction in the setting of a randomized clinical trial. Proc Intl Soc Mag Reson Med 11. 2003. http://cds.ismrm.org/ismrm-2003/0412.pdf. Accessed January 14, 2014.

22. Hekimoglu K, Ustundag Y, Dusak A, et al. MRCP vs. ERCP in the evaluation of biliary pathologies: review of current literature. J Dig Dis. 2008;9(3):162–169.

23. Maple JT, Ben-Menachem T, Anderson MA, et al.; ASGE Standards of Practice Committee. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010;71(1):1–9.

24. Wilson PG. Indications and complications of ERCP. http://www.mgns.org.uk/resources/INDICATIONS+AND+COMPLICATIONS+OF+ERCP.pdf. Accessed January 14, 2014.

25. Mori T, Sugiyama M, Atomi Y. Gallstone disease: Management of intrahepatic stones. Best Pract Res Clin Gastroenterol. 2006;20(6):1117–1137.

26. Murshid KR. Asymptomatic gallstones: should we operate? Saudi J Gastroenterol. 2007;13(2):57–69,

27. Vetrhus M, Søreide O, Solhaug JH, Nesvik I, Søndenaa K. Symptomatic, non-complicated gallbladder stone disease. Operation or observation? A randomized clinical study. Scand J Gastroenterol. 2002;37(7):834–839.

28. Sarkio S, Salmela K, Kyllönen L, Rosliakova M, Honkanen E, Halme L. Complications of gallstone disease in kidney transplantation patients. Nephrol Dial Transplant. 2007;22(3):886–890.

29. Amaral JF, Thompson WR. Gallbladder disease in the morbidly obese. Am J Surg. 1985;149(4):551–557.

30. Venneman NG, Renooij W, Rehfeld JF, et al. Small gallstones, preserved gallbladder motility, and fast crystallization are associated with pancreatitis. Hepatology. 2005;41(4):738–746.

31. Brosseuk D, Demetrick J. Laparoscopic cholecystectomy for symptoms of biliary colic in the absence of gallstones. Am J Surg. 2003;186(1):1–3.

32. Henderson SO, Swadron S, Newton E. Comparison of intravenous ketorolac and meperidine in the treatment of biliary colic. J Emerg Med. 2002;23(3):237–241.

33. Kumar A, Deed JS, Bhasin B, Kumar A, Thomas S. Comparison of the effect of diclofenac with hyoscine-N-butylbromide in the symptomatic treatment of acute biliary colic. ANZ J Surg. 2004;74(7):573–576.

34. Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev. 2006;(4):CD006231.

35. Sherwinter DA, Subramanian SR, Cummings LS, et al. Laparoscopic cholecystectomy. http://emedicine.medscape.com/article/1582292-overview. Accessed March 25, 2014.

36. Tayeb M, Raza SA, Khan MR, Azami R. Conversion from laparoscopic to open cholecystectomy: multivariate analysis of preoperative risk factors. J Postgrad Med. 2005;51(1):17–20, discussion 21–22.

37. Kologlu M, Tutuncu T, Yuksek YN, Gozalan U, Daglar G, Kama NA. Using a risk score for conversion from laparoscopic to open cholecystectomy in resident training. Surgery. 2004;135(3):282–287.

38. Choudhary A, Bechtold ML, Puli SR, Othman MO, Roy PK. Role of prophylactic antibiotics in laparoscopic cholecystectomy: a meta-analysis. J Gastrointest Surg. 2008;12(11):1847–1853.

39. Sanabria A, Dominguez LC, Valdivieso E, Gomez G. Antibiotic prophylaxis for patients undergoing elective laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2010;(12):CD005265.

40. Woods RK, Dellinger EP. Current guidelines for antibiotic prophylaxis of surgical wounds. Am Fam Physician. 1998;57(11):2731–2740.

41. Steel PA, Sharma R. Acute cholecystitis and biliary colic in emergency medicine. http://emedicine.medscape.com/article/1950020-overview#aw2aab6c18. Accessed March 25, 2014.

42. Tandan M, Reddy DN, Santosh D, et al. Extracorporeal shock wave lithotripsy of large difficult common bile duct stones: efficacy and analysis of factors that favor stone fragmentation. J Gastroenterol Hepatol. 2009;24(8):1370–1374.

43. Tandan M, Reddy DN. Extracorporeal shock wave lithotripsy for pancreatic and large common bile duct stones. World J Gastroenterol. 2011;17(39):4365–4371.

44. Gurusamy KS, Samraj K, Ramamoorthy R, Farouk M, Fusai G, Davidson BR. Miniport versus standard ports for laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2013;(8):CD006804.

45. Navarra G, Currò G. SILS and NOTES cholecystectomy: a tailored approach. ANZ J Surg. 2010;80(11):769–770.

46. Date RS, Kaushal M, Ramesh A. A review of the management of gallstone disease and its complications in pregnancy. Am J Surg. 2008;196(4):599–608.

47. Jackson H, Granger S, Price R, et al. Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review. Surg Endosc. 2008;22(9):1917–1927.

48. Adedeji OA, McAdam WA. Murphy's sign, acute cholecystitis and elderly people. J R Coll Surg Edinb. 1996;41(2):88–89.

49. McGillicuddy EA, Schuster KM, Barre K, et al. Non-operative management of acute cholecystitis in the elderly. Br J Surg. 2012;99(9):1254–1261.

50. Morse BC, Smith JB, Lawdahl RB, Roettger RH. Management of acute cholecystitis in critically ill patients: contemporary role for cholecystostomy and subsequent cholecystectomy. Am Surg. 2010;76(7):708–712.

51. Spira RM, Nissan A, Zamir O, Cohen T, Fields SI, Freund HR. Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis. Am J Surg. 2002;183(1):62–66.

52. Hamad MA, Thabet M, Badawy A, et al. Laparoscopic versus open cholecystectomy in patients with liver cirrhosis: a prospective, randomized study. J Laparoendosc Adv Surg Tech A. 2010;20(5):405–409.



Copyright © 2014 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Information From Industry

More in AFP


Related Topic Searches


Editor's Collections


More in Pubmed

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article