Gallstones

Scope

  • the assessment and management of both symptomatic and asymptomatic gallstones in adults
  • the assessment and management of conditions commonly associated with gallstones in adults, such as:
    • common bile duct stones (CBDS)
    • acute cholecystitis
    • acute cholangitis
Definition
  • gallstones are abnormal masses of a solid mixture of cholesterol crystals, mucin, calcium bilirubinate, and proteins
  • divided into the following categories, based upon their composition:
    • pure cholesterol stones
    • pure pigment stones
    • mixed stones

Out of scope

  • the assessment and management of gallstones (and associated conditions) in children
  • the assessment and management of acute pancreatitis

Assessment

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

Red Flags

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

Investigations

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

Management

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

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

Supporting Information

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

 

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