Hospital Medicine

Cholelithiasis (gallstones)

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Cholelithiasis (gallstones)

I. What every physician needs to know.

Cholelithiasis, also known as gallstones, can be symptomatic or asymptomatic. Asymptomatic gallstones may be found incidentally on abdominal computed tomography (CT) or abdominal ultrasound (US) scan and generally warrant no further work-up or treatment. Symptomatic uncomplicated gallstones are generally diagnosed clinically. Biliary colic is the classic presentation of symptomatic gallstones. Uncomplicated (either asymptomatic or symptomatic) cholelithiasis is typically cared for on an outpatient basis and does not require admission to a hospital.

II. Diagnostic Confirmation: Are you sure your patient has cholelithiasis?

Cholelithiasis is best diagnosed by abdominal US.

A. History Part I: Pattern Recognition:

The classic presentation of symptomatic cholelithiasis is "biliary colic". Biliary colic is typically described as dull right upper quadrant (RUQ) pain that comes on after a fatty meal (about 1 hour after). It can be moderate to severe in nature and is often constant for 1-3 hours, then resolves spontaneously (when the gallstone which has become impacted in the cystic duct drops back into the gallbladder). It can be associated with nausea, vomiting and diaphoresis. Patients often have recurrent stereotypical attacks before seeking medical attention.

B. History Part 2: Prevalence:

Risk factors include:

  • Age greater than 40 years

  • Female

  • Obesity

  • Rapid weight loss

  • Cirrhosis

  • Hemolysis

  • Oral contraceptives

  • Pregnancy

  • Gallbladder stasis (total parenteral (TPN) administration/fasting)

  • Medications (e.g. Ceftriaxone)

C. History Part 3: Competing diagnoses that can mimic cholelithiasis.

The following can be confused with symptomatic cholelithiasis:

  • Acute coronary syndrome

  • Dyspepsia

  • Peptic ulcer disease

  • Zoster

  • Hepatitis

  • Pulmonary embolus

  • Acute cholecystitis: should be accompanied by fever and leukocytosis. Pain is often more persistent as well.

  • Acute pancreatitis

  • Right lower lobe pneumonia

  • Fitz-Hugh Curtis Syndrome

D. Physical Examination Findings.

Patients are most often asymptomatic by the time they seek attention for biliary colic and have no abnormal physical findings directly attributable to gallstone disease.

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

All laboratory tests should be normal in symptomatic uncomplicated cholelithiasis and asymptomatic cholelithiasis. Laboratory tests can be performed to rule out any of the above differential diagnoses if they are likely. In addition, if pain has been longstanding, the diagnosis of acute cholecystitis should be entertained, and complete blood count (CBC) can be sent to look for elevated white blood cell (WBC) count.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

Gallstones are best visualized by RUQ ultrasound, which shows acoustic shadowing foci, which are gravity dependent.

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

Although stones may be seen on CT scanning, it has poor sensitivity since stones are often isodense to bile.

III. Default Management.

Pain control is the mainstay of treatment of symptomatic uncomplicated cholelithiasis. Patients should remain nil per os (NPO) while pain is present.

A. Immediate management.

Address pain control with either narcotics or non-steroidal anti-inflammatory drugs (NSAIDs). Patients may require intravenous (IV) hydration. Ketorolac appears to be as effective as meperidine.

B. Physical Examination Tips to Guide Management.

Patients should continue to have a normal physical exam. Pain is usually relieved with the above management in 15-20 minutes. Overall, it is unusual to have continuous abdominal pain for more than 2-3 hours.

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

None

D. Long-term management.

Most patients with asymptomatic gallstones require no further follow-up. Patients with symptomatic gallstones should undergo cholecystectomy if they are deemed good surgical candidates. If they are felt to be poor surgical candidates, they can receive medical therapy to either dissolve (oral bile salts, contact dissolution) or destroy (extra corporeal shockwave lithotripsy) the stones. Percutaneous cholecystostomy tubes can also be used for symptomatic patients who are too ill to undergo the above therapies.

E. Common Pitfalls and Side-Effects of Management.

Differentiate clinically between symptomatic uncomplicated cholelithiasis (biliary colic) and acute cholecystitis.

A. Renal Insufficiency.

No change in standard management.

B. Liver Insufficiency.

No change in standard management.

C. Systolic and Diastolic Heart Failure.

No change in standard management.

D. Coronary Artery Disease or Peripheral Vascular Disease.

No change in standard management.

E. Diabetes or other Endocrine issues.

No change in standard management.

F. Malignancy.

No change in standard management.

G. Immunosuppression (HIV, chronic steroids, etc).

No change in standard management.

H. Primary Lung Disease (COPD, Asthma, ILD).

No change in standard management.

I. Gastrointestinal or Nutrition Issues.

Due to the high incidence of gallstone development after gastric bypass surgery (30-40%), some experts recommend prophylactic cholecystectomy at the time of bypass surgery.

J. Hematologic or Coagulation Issues.

Due to the high incidence of gallstone development (>50%), patients with certain haemolytic disorders (particularly sickle cell disease and hereditary spherocytosis) may benefit from prophylactic cholecystectomy.

K. Dementia or Psychiatric Illness/Treatment.

No change in standard management.

A. Sign-out considerations While Hospitalized.

Cholelithiasis is generally cared for on an outpatient basis.

B. Anticipated Length of Stay.

Cholelithiasis is generally cared for on an outpatient basis.

C. When is the Patient Ready for Discharge.

Cholelithiasis is generally cared for on an outpatient basis.

1. When should clinic follow up be arranged and with whom.

Patients with symptomatic cholelithiasis should have surgical or gastrointestinal follow-up within several weeks to set up definitive treatment. Risk of emergent hospital readmission in the first week after Emergency Department visits for symptomatic gallstones increases dramatically when patients do not follow up with a physician.

2. What tests should be conducted prior to discharge to enable best clinic first visit.

None

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.

None

E. Placement Considerations.

None

F. Prognosis and Patient Counseling.

A small percentage (10-25%) of patients with asymptomatic gallstones will develop biliary colic within 10 years. Patients with symptomatic gallstones should avoid fatty foods. Patients should return to the emergency department for persistent (more than 3 hours) biliary colic, particularly if it is associated with fever or vomiting.

A. Core Indicator Standards and Documentation.

N/A

B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

N/A

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