What is the primary care management of cholelithiasis (gallstones)?

From the Guidelines

Asymptomatic gallstones should be managed with expectant management, as the risks of surgical and nonsurgical intervention outweigh their benefits, according to the American College of Physicians guidelines 1. Management of cholelithiasis in primary care involves assessing symptoms, stratifying risk, and referring patients appropriately.

• For asymptomatic gallstones, expectant management is recommended, as most patients will remain asymptomatic and the effort and minor risks of intervention outweigh their benefits 1.
• Patients with a high risk for gallbladder cancer, such as those with calcified gallbladders or large stones, may be exceptions to this recommendation and should be considered for prophylactic cholecystectomy 1.
• For symptomatic gallstones, the choice of treatment is more complicated and involves determining the patient's treatment goals and attitudes, as well as assessing the natural history of the disease 1.
• The clinician should determine if the biliary pain is the first episode and whether the pain indicates gallstone disease, and advise the patient on the likelihood of future episodes and the risks and benefits of treatment 1.
• Patients with symptomatic gallstones who want to prevent another episode of pain should be considered for treatment, which may include laparoscopic cholecystectomy, the definitive treatment for symptomatic gallstones 1.

From the Research

Cholelithiasis Management in Primary Care

• Cholelithiasis affects approximately 15% of the US population, with rising trends in obesity and metabolic syndrome contributing to an increase in diagnosis 2.
• The classic presentation of cholelithiasis is right upper quadrant pain of the abdomen, often elicited upon palpation during physical examination and documented as a positive Murphy's sign 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.

Diagnostic Approaches

• Ultrasonography is the gold standard for diagnosis of cholelithiasis 2, 3.
• Laboratory tests such as white blood cell count, liver enzymes, amylase, and lipase may assist in diagnosing cholelithiasis 2.
• Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography are superior to US in detecting choledocholithiasis 3.

Treatment Options

• Medication management, such as use of gallstone dissolution agents, may be recommended for persons with a single symptomatic episode 2.
• Laparoscopic cholecystectomy is recommended for individuals with severe and/or recurrent symptoms 2, 4.
• Intraoperative ultrasound and prophylactic ursodiol may be used to prevent gallstone formation following laparoscopic gastric bypass 5.
• Endoscopic and surgical approaches are available for the management of cholelithiasis with choledocholithiasis, with a debate existing on the ideal management strategy 4.

Guidelines and Recommendations

• The Japanese Society of Gastroenterology has revised evidence-based clinical practice guidelines for cholelithiasis, which provide flexibility in choices according to the actual clinical environment 6.
• Individuals with an established diagnosis of cholelithiasis should be referred to a surgeon and/or gastroenterologist within 2 weeks of initial presentation, regardless of severity or frequency of symptoms 2.