Cholelithiasis (Gallstones)

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

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ACUTE

symptomatic cholelithiasis

1st line – cholecystectomy

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1st line –

cholecystectomy

Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis and should be performed as soon as possible; prompt surgical treatment decreases surgical morbidity, operating time, and duration of hospital stay.[1][72][101][102][103]

Clinical decision tools have identified patient attributes in those with uncomplicated symptomatic gallstone disease that are associated with the most benefit from cholecystectomy: a high baseline pain score, pain radiating through to the back, a positive response to simple analgesia, nausea, absence of a history of heartburn, no previous abdominal surgery, and advanced age.[104]

Most patients with symptomatic cholelithiasis should be considered for laparoscopic cholecystectomy, unless they are unable to tolerate general anesthesia or have a serious cardiopulmonary disease or other comorbidity that makes surgery unsuitable.[102]

Despite similarities in mortality and complications between laparoscopic and open cholecystectomy, laparoscopic surgery is associated with reduced length of hospital stay and shorter recovery time, and so is preferred.[1][97][101]

In pregnant patients, laparoscopic cholecystectomy is preferred and ideally carried out in the second trimester.[72][106]

Open laparotomy is indicated (occasionally, in practice) if laparoscopy is technically difficult (e.g., it is difficult to establish pneumoperitoneum, key anatomy is not clear, or there is concern for possible iatrogenic injury), if there is inflammation, adhesions, intra-abdominal fat, or bleeding/untreated coagulopathy, or if gallbladder cancer is suspected.[31][72][102][107]

Patients are usually consented to the initial laparoscopic approach and conversion to an open procedure may be required.

Patients with uncomplicated gallstone pancreatitis should undergo laparoscopic cholecystectomy during the same admission (ideally within 48 hours).[20]

Plus – supportive care

choledocholithiasis with or without symptoms

1st line – endoscopic retrograde cholangiopancreatography (ERCP)

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1st line –

endoscopic retrograde cholangiopancreatography (ERCP)

Documented common bile duct stones warrant removal because they may cause serious obstructive complications such as acute cholangitis, hepatic abscess, or pancreatitis.[31][97][108][109] A combination of biliary pain, gallbladder stones, a dilated common bile duct (>6 mm) on ultrasonography, and abnormal liver biochemistry (particularly an elevated bilirubin >68 micromoles/L or >4 g/dL) or pancreatic enzyme elevation suggests that a stone may have migrated into the common bile duct.[1]

Choledocholithiasis is best detected through endoscopic ultrasound or magnetic resonance cholangiopancreatography.[75]

ERCP with biliary sphincterotomy and stone extraction is the treatment of choice to avoid complications from choledocholithiasis.[20][97][109] [ ] [Evidence B] In about 10% to 15% of patients, sphincterotomy with standard extraction techniques is not successful and usually due to the stone being large (>1.5 cm), impacted, or located proximal to a stricture.[110] These patients require lithotripsy (fragmentation), papillary balloon dilation, and long-term biliary stenting.[20][75][109][110][111]

Following endoscopic stone extraction, definitive treatment with cholecystectomy reduces the risk of recurrent biliary events, in particular cholangitis or pancreatitis.[1][112] For most patients with simultaneous gallbladder and bile duct stones, early laparoscopic cholecystectomy should generally follow ERCP and stone extraction as soon as any anesthetic or surgical issues are resolved (within 24-72 hours).[1][20][113] One Cochrane review compared the benefits and harms of this two-stage procedure with the "laparoscopic‐endoscopic rendezvous", which combines the two techniques in a single‐stage operation. There was insufficient evidence to determine the effects of the laparoscopic‐endoscopic rendezvous versus preoperative endoscopic sphincterotomy techniques in people undergoing laparoscopic cholecystectomy in terms of mortality and morbidity.[114] Although no firm conclusions could be drawn, the single stage procedure may have longer operating times but reduce the overall length of hospital stay.[20][114]

Plus – supportive care

Consider – lithotripsy, papillary balloon dilation, or long-term biliary stenting

2nd line – laparoscopic common bile duct exploration

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2nd line –

laparoscopic common bile duct exploration

Laparoscopic common bile duct exploration, although technically difficult, is as effective for stone clearance as ERCP performed prior to or after cholecystectomy and has demonstrated similar rates of mortality and morbidity.[115][116][117] [ ] [Evidence B]

For patients at an intermediate risk of a common bile duct stone (abnormal liver biochemistry with more modest bilirubin elevations; biliary pancreatitis; and age >55 years), initial cholecystectomy with intraoperative cholangiography and common bile duct exploration may shorten hospitalization without increasing complications.[75][97][118]

Laparoscopic common bile duct exploration should also be considered in patients with surgically altered anatomy (e.g., gastric surgery) or failed ERCP.[119]

Plus – supportive care

ONGOING

asymptomatic cholelithiasis

1st line – observation

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1st line –

observation

Patients who have cholelithiasis with no symptoms do not usually require treatment; in most people, the risk of surgical complications outweighs the risk of leaving the gallstones untreated.[1][16][31] Annual follow-up of asymptomatic patients is recommended.[31]

Prophylactic cholecystectomy in asymptomatic individuals might be considered if there is high risk of gallbladder carcinoma (e.g., gallstones >3 cm, multiple gallstones, or a partially calcified "porcelain" gallbladder), or when the risk of gallstone formation and its complications are high (e.g., in those with sickle cell disease).[27][2][31] Prophylactic cholecystectomy is generally not routinely recommended for obese patients undergoing weight loss surgery. Rather, cholecystectomy should be reserved for obese patients who become symptomatic following surgery.[1][98]

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Cholelithiasis (Gallstones)

Treatment algorithm

symptomatic cholelithiasis

cholecystectomy

supportive care

choledocholithiasis with or without symptoms

endoscopic retrograde cholangiopancreatography (ERCP)

supportive care

lithotripsy, papillary balloon dilation, or long-term biliary stenting

laparoscopic common bile duct exploration

supportive care

asymptomatic cholelithiasis

observation