What are the next steps for a patient with a history of cholelithiasis and ongoing colicky pain, who previously had a cancelled cholecystectomy due to funding issues?

From the Guidelines

The patient should be referred back to general surgery for evaluation of her persistent colicky pain related to cholelithiasis (gallstones). She previously had a scheduled gallbladder removal surgery that was canceled due to funding issues, and despite dietary changes, she continues to experience symptoms. While a repeat ultrasound would typically be recommended to reassess her gallbladder condition before surgical consultation, the patient has declined this imaging at present. A new referral to general surgery is appropriate as requested by the patient, as the surgical department has indicated this is necessary to reestablish care. The patient should be advised that the surgeon may still request updated imaging before proceeding with surgical planning.

Key Considerations

• Cholecystectomy (gallbladder removal) remains the definitive treatment for symptomatic cholelithiasis, as dietary modifications alone often provide only partial symptom relief 1.
• The persistent colicky pain suggests ongoing biliary colic from gallstones, which can lead to complications such as cholecystitis, pancreatitis, or biliary obstruction if left untreated.
• Early cholecystectomy is a safe treatment for acute cholecystitis and generally results in shorter recovery time and hospitalization compared to delayed cholecystectomies 1.

Management Approach

• The patient should continue her current medication regimen since she reports feeling good with it, and maintain a low-fat diet to minimize gallbladder stimulation and pain episodes.
• It is essential to follow up with the general surgery team to discuss the best course of action for her specific situation, considering the previous cancellation of surgery and current symptoms.
• The patient's history of cholelithiasis and previous scheduled surgery for gallbladder removal, which was canceled due to funding issues, supports the need for a thorough evaluation by the general surgery team to determine the best approach for her care.

From the Research

Patient's Current Condition

• The patient is feeling good with her current medication regimen and has an upcoming gynecology referral appointment scheduled for June 6,2025.
• She has a history of cholelithiasis and was previously scheduled for surgery to have her gallbladder removed, but it was cancelled due to funding issues.
• The patient has changed her diet but continues to experience colicky pain and would like to be referred back to the general surgery team.

Previous Diagnosis and Treatment

• The patient was diagnosed with cholelithiasis, which affects approximately 15% of the US population 2.
• Women are more likely to experience cholelithiasis than men, and pregnancy, increasing parity, and obesity during pregnancy further increase the risk 2.
• The patient's symptoms, such as colicky pain, are consistent with cholelithiasis, and the classic presentation of the disease includes right upper quadrant pain, nausea, and vomiting 2.

Management and Treatment Options

• Management of cholelithiasis is dependent on the severity and frequency of symptoms, and lifestyle and dietary modifications combined with medication management may be recommended for persons with a single symptomatic episode 2.
• If symptoms become severe and/or recurrent, laparoscopic cholecystectomy is recommended 2.
• The patient's request to be referred back to the general surgery team is consistent with the recommendation that individuals with an established diagnosis of cholelithiasis be referred to a surgeon and/or gastroenterologist within 2 weeks of initial presentation, regardless of severity or frequency of symptoms 2.
• Other treatment options, such as endoscopic and surgical approaches, may be considered for patients with choledocholithiasis, a condition where gallstones are present in the common bile duct 3.
• A systematic review of treatment options for symptomatic cholelithiasis found that surgery, non-surgical therapies, and ED pain management strategies may be effective, but more research is needed to guide comparisons between treatment methods 4.

Diagnostic Evaluation

• The patient declined a repeat ultrasound at this time, but ultrasonography is the gold standard for diagnosing cholelithiasis 2.
• Laboratory tests, such as white blood cell count, liver enzymes, amylase, and lipase, may assist in diagnosing cholelithiasis, but lack of physical examination findings does not rule out a diagnosis of cholelithiasis 2.
• Clinical diagnosis of cholecystitis in emergency department patients with cholelithiasis is an indication for urgent cholecystectomy, and sensitivity of clinical diagnosis was superior to US findings as compared to pathologic diagnosis of cholecystitis 5.
• Atypical manifestations of cholelithiasis, such as chronic right back pain, should be considered in the diagnostic evaluation, and endoscopic ultrasound may be useful in ruling out microlithiasis when abdominal ultrasound is negative 6.