Cholelithiasis, characterized by the presence of gallstones, is a common condition in the United States, with 80% of affected individuals having no symptoms. Symptomatic gallstone disease encompasses symptomatic cholelithiasis, biliary dyskinesia, acute cholecystitis, choledocholithiasis, gallstone pancreatitis, and acute cholangitis. It often manifests as sharp, stabbing right upper quadrant or epigastric pain as well as nausea and vomiting. History, physical examination, and laboratory evaluation alone are insufficient to make an accurate diagnosis. Ultrasonography should be the first-line imaging modality for evaluating right upper quadrant pain. Symptomatic cholelithiasis is diagnosed with the confirmation of gallstones on imaging in patients presenting with classic symptoms. Clinical prediction tools such as the 2018 Tokyo guidelines for acute cholecystitis or pretest probability calculation for choledocholithiasis should be used to aid diagnosis and determine the need for further imaging. Laparoscopic cholecystectomy is the standard treatment for most forms of symptomatic gallstone disease. In cases of choledocholithiasis, intraoperative common bile duct exploration at the time of cholecystectomy or endoscopic retrograde cholangiopancreatography performed before, during, or after cholecystectomy is needed.
Case 2. HK is a 49-year-old female who presents with a several-day history of worsening right upper quadrant abdominal pain. She has a history of gastroesophageal reflux disease and obesity. She reports several weeks of intermittent abdominal pain after eating fatty and spicy foods. She awoke this morning with severe, sharp right upper quadrant abdominal pain associated with nausea and has not been able to tolerate any liquids or food today.
Epidemiology
Cholelithiasis, the presence of gallstones, affects 10% to 15% of US adults; however, almost 80% of individuals with gallstones are asymptomatic.1 Risk factors for cholelithiasis include female sex, older age, obesity, rapid weight loss, type 2 diabetes, and metabolic dysfunction–associated steatotic liver disease.2 Crohn disease is another risk factor, with cholelithiasis more common in those with a long duration of disease and an age of 40 years or older.3 There is a higher prevalence of cholelithiasis in people with Hispanic and Indigenous American ancestry that is not due to genetic markers, which suggests lifestyle or dietary differences as a possible explanation.1 Approximately 12% of pregnant patients have cholelithiasis, with 3% of affected patients requiring surgery during pregnancy.2
Cholelithiasis is a well-known postoperative complication of bariatric surgery, more common in White people and females, with 10% of patients undergoing this surgery subsequently requiring cholecystectomy.4 Several medications associated with increased risk of cholelithiasis include octreotide, ceftriaxone, and glucagon-like peptide-1 (GLP-1) receptor agonists.2 Use of a GLP-1 receptor agonist at higher doses for weight loss and for longer than 26 weeks increases the incidence of cholelithiasis.5 In children, the most common cause of cholelithiasis is hemolytic anemia, resulting in pigment stones.1 The prevalence of cholelithiasis among young people has risen to between 1.9% and 4%; the increase appears to be primarily related to cholesterol stones.6
Pathophysiology
Gallstone disease includes asymptomatic cholelithiasis as well as symptomatic cholelithiasis, choledocholithiasis, acute cholecystitis, gallstone pancreatitis, and acute cholangitis. Cholelithiasis is secondary to supersaturation of bile with insoluble compounds such as cholesterol.7 Gallstones are classified by their composition and appearance. Cholesterol stones are yellow and represent 90% of all cases.8 Pigment stones are black or brown and form because of hemolysis or biliary tract infection, respectively.7
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