Gallstones are highly prevalent, but most 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 hospitalization 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.
History and exam
Key diagnostic factors
- right upper quadrant or epigastric pain (lasting >30 minutes)
Other diagnostic factors
- postprandial pain
- right upper quadrant or epigastric tenderness
- increasing age
- female sex
- Hispanic and Native American ethnicity
- family history of gallstones
- gene mutations
- pregnancy/exogenous estrogen
- obesity, diabetes, and metabolic syndrome
- nonalcoholic liver disease
- prolonged fasting/rapid weight loss
- total parenteral nutrition (TPN)
- incretin-based drugs
- terminal ileum disease or resection
- low-fiber diet
- helicobacter pylori gallbladder infection
1st investigations to order
- serum LFTs
- serum lipase or amylase
- abdominal ultrasound
Investigations to consider
- abdominal CT scan
- magnetic resonance cholangiopancreatography (MRCP)
- endoscopic ultrasound scan (EUS)
- endoscopic retrograde cholangiopancreatography (ERCP)
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.
Timothy B. Gardner, MD
Director of Pancreatic Disorders
Section of Gastroenterology
Dartmouth-Hitchcock Medical Center
TBG declares that he has no competing interests.
Ajith Siriwardena, MD, FRCS
Professor of Hepatobiliary Surgery
Manchester Royal Infirmary
AS declares that he has no competing interests.
Kurinchi Gurusamy, MBBS, MS, MRCS, MSc (Healthcare informatics)
Clinical Research Fellow
Hepatopancreatobiliary and Liver Transplant Surgery
University Department of Surgery
Royal Free Campus
UCL Medical School
KG declares that he has no competing interests.
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