Gallstones

Signs and Symptoms

Asymptomatic

• see management section
• typically found incidentally on imaging
• become problematic in about:
  • 1-4% of patients within a year
  • 10% of patients within 10 years
  • 20% of patients within 20 years
• most patients will experience symptoms of biliary colic before developing complications
• the longer the gallstones remain quiescent, the less likely the patient is to develop complications

Symptomatic

• biliary colic
  • caused by the gallbladder contracting against an obstructed cystic duct
  • patients present with pain that is:
    • severe - can last from 15 minutes to 24 hours and may wake patient at night
    • intermittent - typically separated by weeks/months
    • located in the right upper quadrant or epigastric region - may radiate to the right scapula, shoulder or, occasionally, retrosternally
  • gradually resolving:
    • resolves when the gallbladder stops contracting, or the cystic duct becomes patent again
    • either spontaneously or with analgesics
    • pain that does not resolve could be indicative of a complication
  • typically brought on by fatty foods
  • sometimes associated with diaphoresis, nausea, and/or vomiting
  • atypically associated with belching, bloating, flatulence, and/or dyspepsia
• acute cholecystitis or empyema
• acute pancreatitis
• common bile duct stones (CBDS)
• acute cholangitis
• obstructive jaundice
• mucocoele of gallbladder
• gallstone ileus - rare

Severe complications affect only 1-3% of symptomatic gallstone patients

History and Examination

History

For symptomatic patients take a thorough history to include details of:

• symptoms:
  • pain:
    • onset
    • severity
    • site
    • nature (biliary colic rarely has features of a colic)
    • aggravating and relieving factors
  • nausea and vomiting
  • jaundice
  • fever, chills, or rigors
  • change in bowel habit
  • weight loss
• previous episodes of biliary colic
• past history of gallstone disease
• family history of gallstone disease
• current medications

Examination

Perform a thorough examination to check for signs of associated complications, such as:

• signs of:
  • inflammation, e.g. fever
  • an acute abdomen
• a positive Murphy's sign - indicative of inflammation associated with acute cholecystitis

Uncomplicated biliary colic should reveal normal vital signs and physical examination. Also check for:

• Charcot's cholangitis triad (or Charcot's triad 2):
  • pain, jaundice, and fever (usually with rigors)
  • indicative of acute cholangitis
• Courvoisier's 'law':
  • painless jaundice and a palpable gallbladder
  • suggests obstruction from pathology other than gallstones, e.g. pancreatic malignancy

An initial clinical assessment will identify:

• patients with known gallstone disease who:
  • require urgent surgical assessment for serious complications
  • present with increasingly frequent and painful episodes of biliary colic, for whom conservative therapy has failed and definitive surgical intervention should be considered
• patients with asymptomatic gallstones who present with atypical symptoms and signs:
  • symptoms should not automatically be attributed to cholelithiasis
  • may require further investigation to exclude other causes of epigastric/right upper quadrant pain, including:
  • gastritis/peptic ulcer disease
  • myocardial ischaemia/infarction (MI)
  • pancreatitis
  • hepatitis
  • inflammatory or neoplastic disease of the colon
  • liver/subphrenic abscess
  • oesophageal spasm
  • irritable bowel syndrome
• patients who have developed atypical pain and/or non-specific symptoms (e.g. chronic indigestion, vague abdominal pain, bloating, belching) - may merit further investigation

Differential Diagnoses

• Alternative causes of epigastric/right upper quadrant (RUQ) pain include:
  • gastritis/peptic ulcer disease
  • myocardial ischaemia/infarction (MI)
  • pancreatitis
  • hepatitis
  • inflammatory or neoplastic disease of the colon
  • liver/subphrenic abscess
  • oesophageal spasm
  • irritable bowel syndrome

Joint Formulary – Chapter 1 - Gastrointestinal

If there is suspicion of any of the following, consider urgent referral to secondary care Surgical Assessment Unit (SAU):

• haemodynamic compromise
• acute abdomen:
  • guarding indicates localised/generalised peritonitis
  • acute intestinal obstruction (rare)
• acute cholecystitis:
  • persistent right upper quadrant (RUQ)/epigastric pain with marked tenderness
  • a positive Murphy's sign:
  • indicative of inflammation associated with acute cholecystitis
  • elicited by asking the patient to inspire deeply with the examining hand immediately below the right costal margin in the mid-clavicular line
  • an inflamed gallbladder is indicated by patient experiencing pain and catching their breath as the gallbladder descends
• low-grade pyrexia (high-grade pyrexia may indicate cholangitis)
• delayed presentation with systematic sepsis from gallbladder abscess (empyema) and rarely perforation
• complications of common bile duct (CBD) stones:
• jaundice:
  • gallstones associated with painful jaundice indicates obstruction of the common bile duct by a gallstone migrating from the gallbladder
  • rarely, a large stone resident in the gallbladder may compress the biliary tree to present in a similar fashion (Mirrizi's syndrome)
  • painless jaundice is rarely attributable to gallstone pathology
  • patients may complain of pale stool and/or dark urine
• acute cholangitis:
  • Charcot's triad of jaundice, RUQ pain, and fever (typically with rigors) is diagnostic
  • indicates super-added infection of the obstructed biliary system
• acute pancreatitis:
  • profuse vomiting
  • central epigastric pain radiating through to the back
  • difficult diagnosis to make in primary care, but should be considered in all unwell patients with a history of gallstones

Blood work

• the majority of patients with episodic biliary colic would demonstrate normal blood results
• elevated inflammatory markers would make the diagnosis of uncomplicated biliary colic unlikely, and should prompt further investigation
• however, mildly elevated liver function tests can be associated with gallstones if testing takes place during an episode of acute pain - these should be rechecked at an interval to ensure resolution and exclude other causes

Imaging

• abdominal ultrasound is the recommended first-line investigation
• sensitivity varies and is operator dependent, but is generally good (79-99%)
• ultrasound findings of a thickened gallbladder wall and pericholecystic fluid suggest the presence of acute cholecystitis
• radionuclide scanning is not useful for the diagnosis of gallstone disease - it has a high sensitivity for the detection of acute cholecystitis but is rarely employed

Asymptomatic management

• Prophylactic cholecystectomy is not recommended in patients with asymptomatic gallstones as the risks of surgical intervention outweigh the perceived benefits.
• Consider for a surgical referral if imaging suggests unusual features such as:
  • Porcelain gallbladder
  • Polyps
• Behavioural modification may reduce the development of symptoms in those with initially asymptomatic gallstones:
  • increased physical activity
  • decreased total calorie intake
  • moderate coffee and nut consumption

Acute episode management

• management of an acute episode of uncomplicated biliary pain or colic should be directed at controlling symptoms such as pain and nausea
• most episodes can be managed at home
• opioid-analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) are both effective for pain management
• patients may be advised not to eat during the acute episode to reduce cholecystokinin-mediated gallbladder contraction
• episodes lasting more than 24 hours or associated with fever should be referred to hospital - suggests acute cholecystitis
• Encourage lifestyle changes to possibly decrease risk of further episodes of biliary colic:
  • increased physical activity
  • decreased total calorie intake
  • moderate coffee and nut consumption

Referral Criteria

Refer urgently to on-call surgical team

• If any red flags

Refer to an upper gastrointestinal (GI) surgeon

• For elective laparoscopic cholecystectomy if:
  • patient expresses desire to undergo surgery
  • patient is medically fit for surgery
• NB: Preoperative and anaesthetic assessment should identify those who are suitable in borderline cases

Referral Instructions

Referral to on-call surgical team

• Contact hospital directly

Referral to upper GI

• Refer using the e-Referral Service
  • Specialty: GI and Liver (Medicine and Surgery)
  • Clinic Type: Gallstones
  • Service: DRSS-Western-GI and Liver (Medicine and Surgery)-Devon CCG-15N

Referral Forms

DRSS Referral Proforma

Patient Information

Gallstones Bupa

Gallbladder removal Bupa

Caring for someone - Directgov

Disabled people - Directgov

Pathway Group

This pathway was signed off by the NEW Devon CCG Western Locality Clinical Pathway Group.

Publication date: 10 February 2015