Surgical and Nonsurgical Management of Gallstones



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

This content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Related editorial: Functional Gallbladder Disorder: An Increasingly Common Diagnosis

  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

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

View 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.

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

The Authors

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.

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.

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