Gallstone Disease Summary

Definition

  • Solid deposit that forms within the gallbladder
  • Cholesterol stones (90% in western countries)
  • Pigmented stones (bilirubin and calcium salts)
  • Mixed stones (combination)

Key Risk Factors

  • Female gender (2-3x higher incidence)
  • Obesity (BMI > 30)
  • Increasing age (>40 years)
  • Rapid weight loss (>1.5kg/week)

Clinical Features

  • Biliary colic (RUQ pain >30 min, <8 hours)
  • Acute cholecystitis (fever, tenderness, Murphy's sign)
  • Obstructive jaundice
  • Cholangitis (Charcot's triad)

Management

  • Abdominal ultrasound for diagnosis
  • LFTs for suspected common bile duct stones
  • Emergency admission for complications
  • Surgical assessment for cholecystectomy

Gallstone Disease: Diagnosis and Management

Medical guidelines for identifying and treating gallstone disease

Pathophysiology

A gallstone (cholelithiasis) is a solid deposit that forms within the gallbladder. Gallstones occur when there is a problem with the chemical composition of bile, which results in precipitation of one or more of the constituents.

Cholesterol Stones

By far the most common in western countries (approximately 90%).

Pigmented Stones

Dark coloured stones made up of bilirubin and calcium salts.

Mixed Stones

A combination of cholesterol and pigment stones.

Risk Factors

Risk Factors

Multiple factors can contribute to the development of gallstones.

Demographic Factors

  • Female gender (2–3 times higher incidence)
  • Increasing age (incidence rises after 40 years)
  • Genetic and ethnic factors

Medical Conditions

  • Crohn's disease
  • Diabetes mellitus
  • Non-alcoholic fatty liver disease
  • Obesity (BMI over 30)

Lifestyle & Medications

  • Diet high in triglycerides and refined carbohydrates
  • Smoking
  • Prolonged fasting/weight loss
  • Use of HRT or oral contraceptives
  • Certain medications (octreotide, GLP-1 analogues, ceftriaxone)

Complications

Potential Complications

Gallstones can lead to several serious complications that may require emergency intervention.

Biliary colic - Pain caused by the gallbladder, cystic duct, or common bile duct contracting around a gallstone.
Acute cholecystitis - Occurs when obstruction of the cystic duct leads to gallbladder inflammation.
Acute pancreatitis - Occurs when a stone migrates and becomes stuck in the biliopancreatic duct.
Obstructive jaundice - Occurs when a partially or completely blocked common bile duct causes bile accumulation.
Uncommon complications - Acute cholangitis, fistula formation, biliary peritonitis, gallbladder mucocele, gallbladder cancer.

Clinical Features

Suspect gallstone disease in people who present with the classical symptoms and signs of symptomatic gallstone disease, or complications of gallstone disease.

Biliary Colic

Steady non-paroxysmal biliary pain occurs in the epigastrium or right upper quadrant
Typically lasts for more than 30 minutes, but less than eight hours
Often severe, and may be associated with nausea and vomiting
Not associated with fever, or abdominal tenderness

Acute Cholecystitis

Sudden-onset, constant, severe pain in the upper right quadrant, lasting several hours
Anorexia, nausea, or vomiting
Fever and tenderness in the upper right quadrant
Murphy's sign positive on examination
Referred pain in the shoulder or interscapular region

Other Presentations

Obstructive jaundice - Yellowish discolouration of the skin, dark urine and pale stools
Cholangitis - Charcot's triad: fever (often with rigors), jaundice, and right upper quadrant abdominal pain
Gallstone pancreatitis - Constant epigastric pain radiating through to the back, and profuse vomiting

Differential Diagnosis

Typical differentiating features between biliary colic, cholecystitis, and cholangitis

Feature Biliary Colic Acute Cholecystitis Ascending Cholangitis
RUQ pain RUQ pain typically lasting < 8 hours, Murphy's sign negative Persistent RUQ pain and tenderness, Murphy's sign positive Persistent RUQ pain and tenderness, Murphy's sign negative
Fever No Yes Yes
Jaundice No No Yes

Diagnostic Tests

If gallstone disease is suspected, appropriate diagnostic tests should be performed to confirm the diagnosis.

Abdominal ultrasound examination - This may confirm the presence of one or more gallstones. The absence of stones on ultrasound scan does not exclude their existence.
Liver function tests (LFTs) - Gallstones in the common bile duct may result in abnormal LFTs.
Magnetic resonance cholangiopancreatography (MRCP) - If ultrasound has not detected common bile duct stones, but the bile duct is dilated and/or liver function test results are abnormal.
Endoscopic ultrasound (EUS) - If MRCP does not allow a diagnosis to be made.

Management

Treatment Approach

Management of gallstone disease depends on symptoms, complications, and patient factors.

Arrange emergency admission for people who are systemically unwell with a suspected complication of gallstone disease, such as acute cholecystitis, cholangitis, or pancreatitis
Confirmation of the diagnosis (including abdominal ultrasound, and blood tests such as a white blood cell count, C-reactive protein, and serum amylase)
Monitoring (for example blood pressure, pulse, and urinary output)
Treatment (may include intravenous fluids, antibiotics, and analgesia)
Surgical assessment for cholecystectomy