• Clinical science
  • Clinician

Cholelithiasis

Summary



Cholelithiasis refers to the presence of abnormal concretions (gallstones) in the gallbladder. About 10–20% of American adults have gallstones. Gallstones most commonly consist of cholesterol but may be pigmented (due to hemolysis or infection) or mixed. Cholelithiasis can manifest with biliary colic (postprandial RUQ pain) but is most commonly an incidental finding in asymptomatic individuals. The diagnosis is confirmed by ultrasound. Symptomatic cholelithiasis is managed with laparoscopic cholecystectomy.

See also “Choledocholithiasis”, “Acute cholecystitis”, and “Acute cholangitis.”

Overview

Cholelithiasis Choledocholithiasis Acute cholecystitis Acute cholangitis
Description
Mechanism
Clinical features
Laboratory findings
  • Normal
Diagnostic imaging
  • US: dilated common bile duct, intrahepatic biliary dilatation
  • MRCP or ERCP: filling defect in the contrast-enhanced duct
  • US: gallbladder wall thickening and/or edema (double wall sign)
  • HIDA scan: nonvisualization of gallbladder > 4 hours after radioactive tracer administration
  • US: biliary dilation, and/or evidence of obstruction (e.g., cholelithiasis), pericholecystic inflammation
  • MRCP if diagnosis uncertain
Treatment

Epidemiology

  • Sex: > (2–3:1)
  • Prevalence: approx. 10–20% of the adult population in developed countries
  • Peak incidence: : > 40 years

References: [1][2]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

General

Cholesterol stones (up to 95% of all stones) [1][2]

During pregnancy, increased estrogen levels cause increased secretion of lithogenic bile (rich in cholesterol), resulting in the formation of cholesterol gallstones. Increased progesterone levels cause smooth muscle relaxation, decreased and impaired gallbladder contraction, and subsequent bile stasis and formation of gallstones.

Rule of the 6 Fs: Fat, Female, Fertile, Forty, Fair-skinned, Family history.

Black pigment stones (< 10% of all stones) [3][4][2]

Mixed/brown pigment stones (< 10% of all stones) [3][4][5][2]

Clinical features

  • Most gallstones are asymptomatic.
  • Biliary colic: constant, dull RUQ pain lasting < 6 hours
    • Especially postprandial: vagal stimulation (e.g., cholecystokinin release following a fatty meal) → gallbladder contraction → attempts to force the stone into the cystic duct
    • May radiate to the epigastrium, right shoulder, and back (referred pain)
  • Nausea, vomiting, early satiety
  • Bloating, dyspepsia

Only a minority of patients with gallstones are symptomatic!

References: [2]

Diagnostics

Approach [2]

Laboratory studies

Laboratory studies are typically normal in uncomplicated cholelithiasis but should be ordered to rule out other acute biliary conditions and/or other causes of acute abdominal pain.

Imaging

RUQ ultrasound

  • Indication: best initial test in suspected symptomatic cholelithiasis [6][7]
  • Characteristic findings [6]

MRI abdomen without and with IV contrast with MRCP [6]

CT abdomen with IV contrast [6]

Abdominal x-ray

  • Indication: usually performed as part of the routine workup of acute abdominal pain
  • Findings and disadvantages: similar to those of CT scan

X-ray and CT scan are rarely diagnostic in cholelithiasis because only 15–20% of stones are radiopaque. Pure cholesterol stones are radiolucent.

Laboratory studies (e.g., WBC count, bilirubin, amylase) are usually normal in uncomplicated cholelithiasis.

Differential diagnoses

Differential diagnosis of RUQ pain

Differential diagnoses of intraluminal gallbladder wall pathology


The differential diagnoses listed here are not exhaustive.

Treatment

Approach [15][16][2]

Treatment of biliary colic [15][17]

Initial supportive therapy of acute biliary disease

Important considerations [17]

  • Consider inpatient management in patients with intractable pain or if there is concern for complications.
  • Most patients may be discharged from the ER once pain has settled if there is no evidence of complications.
  • Advise patients to avoid foods with a high fat content.
  • Schedule an elective cholecystectomy.

Surgical management

Cholecystectomy is usually not indicated in asymptomatic cholelithiasis!

Nonsurgical alternatives [2]

Indications

  • Patients at high risk of complications due to surgery or anesthesia (e.g., recent myocardial infarction)
  • Patients unwilling to undergo surgery

Options

  • Expectant management [15]
    • Lifestyle modifications :
      • Low-fat diet (especially low in saturated fats) [31]
      • Avoid lithogenic drugs, such as estrogen, fibrates. [32]
      • Exercise regularly.
    • Follow-up if symptoms recur
  • Oral bile acid dissolution therapy
    • May be useful in dissolving pure cholesterol stones (i.e., radiolucent stones) that are < 0.5 cm [15]
    • Ursodeoxycholic acid
    • Duration of therapy: 6–24 months [15][31]
    • Advantage: symptomatic improvement even if stones are not completely dissolved [31]
    • Disadvantages
      • Ineffective in mixed stones
      • High recurrence rates [2]
      • Long duration of therapy
      • Requires repeat imaging to track treatment response
  • Extracorporeal shock wave lithotripsy (ESWL)
    • Advantages
    • Disadvantages
      • May need to be combined with endoscopic sphincterotomy for stone clearance
      • Does not prevent recurrence [2]
      • Injury to adjacent solid organs (rare)

Acute management checklist

Cholecystectomy

Definition

Indications [2][33]

Contraindications [33]

Surgical risk scores

  • NSQIP
  • ASA-PS

Timing

Timing of cholecystectomy depends on the indication and individual surgical risks.

Approach [33]

  • Laparoscopic cholecystectomy
  • Open cholecystectomy
    • Typically performed using a right subcostal incision
    • Not routinely performed
    • Indications include:
      • Unsuccessful laparoscopic cholecystectomy
      • Gallbladder cancer
      • As part of a bigger operative procedure that requires an open surgery

Complications [33][42][2]

Intraoperative and early postoperative complications

Delayed complications

Complications

General

Complications due to gallstone impaction at the gallbladder neck or infundibulum

We list the most important complications. The selection is not exhaustive.

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last updated 07/28/2020
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