From the Guidelines
Cholelithiasis is typically managed with laparoscopic cholecystectomy for symptomatic cases, while asymptomatic cases often require no treatment. The diagnosis of cholelithiasis involves a combination of symptoms, signs, and laboratory tests, as no single investigation has sufficient diagnostic power to establish or exclude acute cholecystitis 1. Abdominal ultrasound is the preferred initial imaging technique for patients suspected of having acute cholecystitis, due to its lower costs, better availability, lack of invasiveness, and good accuracy for stones 1.
Some key points to consider in the management of cholelithiasis include:
- The evaluation of the risk for elderly patients with acute cholecystitis should include mortality rate for conservative and surgical therapeutic options, rate of gallstone-related disease relapse, age-related life expectancy, and patient frailty evaluation 1.
- Laparoscopic cholecystectomy is the preferred treatment for acute cholecystitis even in elderly patients, and should always be attempted at first except in case of absolute anesthetic contraindications and septic shock 1.
- Percutaneous cholecystostomy can be considered in the treatment of acute cholecystitis patients who are deemed unfit for surgery, and should be considered as a bridge to cholecystectomy in acutely ill elderly patients deemed unfit for surgery 1.
- The visualization of common bile duct stones on abdominal ultrasound is a very strong predictor of choledocholithiasis, and liver biochemical tests and abdominal ultrasound should be performed in all patients with acute cholecystitis to assess the risk for common bile duct stones 1.
In terms of treatment, laparoscopic cholecystectomy is the definitive treatment for symptomatic cholelithiasis, and patients should follow a low-fat diet to reduce symptoms while waiting for surgery. Pain management can include NSAIDs like ibuprofen or acetaminophen, and antibiotics may be prescribed if infection is suspected 1. Gallstones form when bile contains too much cholesterol or bilirubin, or when the gallbladder doesn't empty properly, and risk factors include female gender, age over 40, obesity, rapid weight loss, and certain medications. Complications can include inflammation, blockage of bile ducts causing jaundice, or pancreatitis, which require urgent medical attention. After gallbladder removal, most people can return to a normal diet, though some may experience temporary digestive changes.
From the Research
Definition and Prevalence of Cholelithiasis
- Cholelithiasis, also known as gallstone disease, affects approximately 15% of the US population 2 and up to 20% of the European population 3.
- It is a common surgical disease, accounting for half of the over one million cholecystectomies performed in the USA annually 4.
Risk Factors and Presentation
- Risk factors for cholelithiasis include modifiable and nonmodifiable factors, with women being more likely to experience the condition than men 2.
- Pregnancy, increasing parity, and obesity during pregnancy further increase the risk of developing cholelithiasis 2.
- The classic presentation of cholelithiasis includes right upper quadrant pain, referred pain to the right supraclavicular region and/or shoulder, nausea, and vomiting 2.
Diagnosis and Management
- Ultrasonography is the gold standard for diagnosing cholelithiasis 2.
- Management is dependent on severity and frequency of symptoms, with lifestyle and dietary modifications combined with medication management recommended for persons with a single symptomatic episode 2.
- Laparoscopic cholecystectomy is recommended for individuals with severe and/or recurrent symptoms 2.
- Ursodeoxycholic acid (UDCA) is a bile acid that dissolves gallstones and may be used in the management of symptomatic gallstone disease, particularly in those unfit for surgery 5.
Treatment Options
- Cholecystectomy is indicated for patients with symptomatic gallstones or sludge, and should be performed laparoscopically with a four-trocar technique, if possible 3.
- UDCA may be effective in preventing cholelithiasis after sleeve gastrectomy, with a significant reduction in the incidence of cholelithiasis and cholecystectomies 6.
- The timing of treatment for gallstone disease is an essential determinant of therapeutic success, with early laparoscopic cholecystectomy recommended for acute cholecystitis 3.