Gallstone disease (cholelithiasis) is highly prevalent, but most cases are asymptomatic.
Common risk factors include older age, female sex and pregnancy, obesity, rapid weight loss, drugs, and a family history.
Abdominal ultrasound provides effective diagnostic imaging.
Laparoscopic cholecystectomy represents definitive treatment for symptomatic patients.
Complications such as cholecystitis, cholangitis, and pancreatitis develop in 0.1% to 0.3% of patients annually.
Gallstones are the most common gastrointestinal disease that requires hospitalisation in developed countries.
Cholelithiasis is the presence of solid concretions in the gallbladder. Gallstones form in the gallbladder but may exit into the bile ducts (choledocholithiasis). Symptoms ensue if a stone obstructs the cystic, bile, or pancreatic duct.
Most gallstones in developed countries (>90%) consist of cholesterol. Cholesterol gallstone formation begins with the secretion of bile supersaturated with cholesterol from the liver. Initiated by nucleating factors such as mucin, microscopic crystals then precipitate in the gallbladder where hypomotility provides time for stone growth.
This topic covers only the diagnosis and management of symptomatic uncomplicated cholelithiasis and asymptomatic or symptomatic choledocholithiasis. For detailed information on the diagnosis and management of patients with acute cholecystitis, acute cholangitis, or acute pancreatitis, see our topics Acute cholecystitis, Acute cholangitis, and Acute pancreatitis.
History and exam
Key diagnostic factors
- right upper quadrant or epigastric pain (typically lasting >30 minutes)
- presence of risk factors
Other diagnostic factors
- postprandial pain
- right upper quadrant or epigastric tenderness
- increasing age
- female sex
- obesity, diabetes, and metabolic syndrome
- family history of gallstones
- gene mutations
- pregnancy/exogenous oestrogen
- non-alcoholic liver disease
- prolonged fasting/rapid weight loss
- total parenteral nutrition (TPN)
- terminal ileum disease or resection
- Hispanic and Native-American ethnicity
- low-fibre diet
- helicobacter pylori gallbladder infection
1st investigations to order
- abdominal ultrasound
- serum LFTs
- serum lipase or amylase
Investigations to consider
- magnetic resonance cholangiopancreatography (MRCP)
- endoscopic ultrasound scan (EUS)
- abdominal CT scan
choledocholithiasis with or without symptoms
Eldon Shaffer, MD, FRCPC
Emeritus Professor of Medicine
Division of Gastroenterology
University of Calgary
ES declares that he has no competing interests.
Professor Eldon Shaffer would like to gratefully acknowledge Dr Vikesh K. Singh and Dr Anthony N. Kalloo, previous contributors to this topic.
VKS and ANK declare that they have no competing interests.
Christian Macutkiewicz, MD, FHEA, FRCS
Consultant General and Hepato-Pancreato-Biliary Surgeon
Clinical Lead for Emergency General Surgery, Gastrointestinal Medicine, and Surgery CSU
Manchester Royal Infirmary
Director of Scientific Programme
Association of Surgeons of Great Britain and Ireland
CM declares that he has no competing interests.
Luke Evans, MBBS, FRCS (GenSurg) MCh, DGM, FEBS (Emerg Surg)
Consultant in Emergency General Surgery
Service Director for Emergency Assessment Unit (Surgical)
Norfolk and Norwich University Hospitals
LE declares that he has no competing interests.
Section Editor, BMJ Best Practice
CP declares that she has no competing interests.
Head of Editorial, BMJ Knowledge Centre
JH declares that she has no competing interests.
Drug Editor, BMJ Best Practice
AM declares that he has no competing interests.
Comorbidities Editor, BMJ Best Practice
JC declares that she has no competing interests.
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