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Gallstone Disease: Common Questions and Answers

Hiten Patel, MD, MPH
Jacqueline Jepsen, MD

American Family Physician. 2024;109(6):518-524.

Author disclosure: No relevant financial relationships.

In the United States, 10% to 15% of adults are affected by gallstones, and cholesterol gallstones are the most prevalent subtype. Risk factors for developing gallstone disease include female sex; older age; certain medications; and having type 2 diabetes mellitus, nonalcoholic fatty liver disease, obesity, rapid weight loss, or hemolytic anemia. Nearly 80% of gallstones are found incidentally and remain asymptomatic. When symptomatic, gallstone disease usually presents as sudden onset right upper quadrant or epigastric abdominal pain. Common complications of gallstones include cholecystitis, choledocholithiasis, gallstone pancreatitis, and ascending cholangitis. The Murphy sign is a specific physical examination finding for acute cholecystitis. Ultrasonography is the initial imaging choice for detecting gallstones and acute cholecystitis. A hepatobiliary iminodiacetic acid (HIDA) scan can be used to evaluate for cholecystitis in patients with negative or equivocal ultrasound findings. Magnetic resonance cholangiopancreatography (MRCP) is an accurate, noninvasive diagnostic test to identify choledocholithiasis, certain malignancies, and biliary obstruction. Nonsteroidal anti-inflammatory drugs are safe and effective in treating pain from acute cholecystitis and biliary colic. Laparoscopic cholecystectomy is the treatment of choice for most patients with biliary colic or acute cholecystitis. Ursodeoxycholic acid and chenodeoxycholic acid should not routinely be used to treat gallstone disease, but they can be used as a nonsurgical alternative for certain patients. Postcholecystectomy syndrome is a potential postoperative complication that presents with abdominal pain, bloating, and diarrhea. (Am Fam Physician. 2024;109(6):518-524. Copyright © 2024 American Academy of Family Physicians.)

Gallstones, or cholelithiasis, are highly prevalent, affecting an estimated 10% to 15% of U.S. adults.1,2 Approximately 80% of all gallstones are cholesterol gallstones, which form because of precipitation of cholesterol.1,3 Black pigment gallstones (10% to 15%) comprise calcium bilirubinate, formed from unconjugated bilirubin deposition, often secondary to chronic hemolysis.2,3 Brown pigment stones (5%) are usually associated with biliary infections.3 Evidence-based answers to common questions about gallstone disease are discussed in this article.

WHAT'S NEW ON THIS TOPIC

Gallstones
Recent meta-analyses have shown that dipeptidyl-peptidase-4 inhibitors (odds ratio = 1.22) and glucagon-like peptide-1 receptor agonists (relative risk = 1.27) increase the risk of gallstone disease, with greater risk in patients with longer duration of use (longer than 26 weeks).
A 2016 Cochrane review showed that nonsteroidal anti-inflammatory drugs provide greater relief from biliary pain compared with placebo (number needed to treat = 3) and antispasmodics (number needed to treat = 3) and no difference in pain control compared with opiates.
A systematic review of patients who underwent cholecystectomy found that 13% developed postcholecystectomy diarrhea.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
The Murphy sign on physical examination can help rule in acute cholecystitis.17 C Systematic review of low-quality studies conducted in emergency departments
Abdominal ultrasonography is the initial imaging choice in patients with right upper quadrant pain and concern for symptomatic cholelithiasis or cholecystitis.21,22 C Consensus recommendations from the American College of Radiology and usual practice
Nonsteroidal anti-inflammatory drugs are safe and effective for relieving pain from biliary colic and acute cholecystitis.27 B Cochrane review of several small and lower-quality studies
Most patients with asymptomatic gallstones can be followed with expectant management.30–32 B Consistent results from several case series of patients followed for up to 24 years
Prophylactic cholecystectomy should be considered in patients with asymptomatic gallstones who have hemolytic anemia, anticipated organ transplant, or neuroendocrine tumors.5,34 C Small prospective cohort study and decision analysis

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 https://www.aafp.org/afpsort.

HITEN PATEL, MD, MPH, is an assistant professor and associate program director in the Department of Family and Community Medicine at The Ohio State University Wexner Medical Center, Columbus.

JACQUELINE JEPSEN, MD, is a resident physician in the Department of Family and Community Medicine at The Ohio State University Wexner Medical Center.

Address correspondence to Hiten Patel, MD, MPH, The Ohio State University College of Medicine, 2231 N High St., Columbus, OH 43201 (hiten.patel@osumc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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