What are the diagnosis and treatment options for cholelithiasis (gallstones)?

Diagnosis and Treatment of Cholelithiasis (Gallstones)

Ultrasound is the gold standard for diagnosing cholelithiasis, with approximately 98% sensitivity for detecting gallstones, while laparoscopic cholecystectomy is the definitive treatment for symptomatic gallstone disease. 1, 2

Diagnosis

Clinical Presentation

• Classic symptoms:
  • Right upper quadrant pain (biliary colic), often occurring 30-60 minutes after meals
  • Pain may radiate to the right supraclavicular region or shoulder
  • Nausea and vomiting
  • Positive Murphy's sign (pain on deep palpation during inspiration)
  • Jaundice (if common bile duct obstruction occurs)

Diagnostic Testing Algorithm

1. Abdominal Ultrasound: First-line imaging test

   • Detects gallstones with ~98% sensitivity
   • Diagnostic findings include:
     • Presence of stones
     • Thickening of gallbladder wall (≥5mm)
     • Pericholecystic fluid
     • Positive ultrasonographic Murphy's sign
   • The combination of stones and positive ultrasonographic Murphy's sign has a 92% positive predictive value 1
   • The combination of stones and thickened gallbladder wall has a 95% positive predictive value 1

2. Hepatobiliary Scintigraphy (HIDA scan):

   • Second-line test when ultrasound is inconclusive
   • Involves IV injection of technetium-labeled analogues of imino-diacetic acid
   • Absence of gallbladder filling within 60 minutes indicates cystic duct obstruction
   • Sensitivity of 80-90% for acute cholecystitis 1
   • Higher sensitivity (84.2%) than ultrasound (67.3%) or CT (59.8%) 1

3. Magnetic Resonance Cholangiopancreatography (MRCP):

   • For suspected common bile duct stones (choledocholithiasis)
   • Accuracy >90% for detecting common bile duct stones
   • Less sensitive for small stones 1

4. Endoscopic Ultrasound (EUS):

   • Minimally invasive procedure for detecting common bile duct stones
   • Sensitivity of 93% and specificity of 96% for CBD stone detection 1
   • At least equal to ERCP for stone detection 1

5. Laboratory Tests:

   • Liver function tests (LFTs)
   • White blood cell count
   • Amylase and lipase (to rule out pancreatitis)
   • Note: Normal LFTs have a negative predictive value of 97% for common bile duct stones, but abnormal LFTs have only 15% positive predictive value 1

Common Diagnostic Pitfalls

• Gallstones may be missed on imaging in up to 2% of cases, even with multiple imaging techniques 3
• Relying solely on LFTs for diagnosis of common bile duct stones is not recommended 1
• Atypical symptoms (indigestion, flatulence, heartburn, bloating) are less likely to resolve following cholecystectomy 1

Treatment

Treatment Algorithm

1. Asymptomatic Gallstones:

   • Generally managed with observation alone (expectant management) 4
   • Only 10-25% of asymptomatic cases progress to symptomatic disease 4
   • Prophylactic cholecystectomy indicated only in specific subgroups:
     • Large gallstones (>2.5 cm)
     • Patients with congenital hemolytic anemia
     • Non-functioning gallbladder
     • During bariatric surgery or colectomy 5

2. Symptomatic Uncomplicated Cholelithiasis:

   • Laparoscopic cholecystectomy is the treatment of choice 1
   • Early cholecystectomy (within 10 days of symptom onset) is preferable to delayed cholecystectomy 1
   • If symptoms have been present for >10 days, delayed cholecystectomy after 45 days is better unless there are signs of worsening peritonitis or sepsis 1

3. Acute Cholecystitis:

   • Initial medical management to stabilize hemodynamic status and treat infection
   • Laparoscopic cholecystectomy is more successful when performed within 3 days of symptom onset 5

4. Choledocholithiasis (Common Bile Duct Stones):

   • Present in 10-20% of patients with gallstone disease 1
   • Treatment options include:
     • Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction (90% success rate) 1
     • For large stones (>10-15mm), lithotripsy or stone fragmentation may be required 1
     • Laparoscopic common bile duct exploration is an option for stone-related non-severe acute cholangitis 1

Special Considerations

• Pregnancy increases risk of gallstone formation 2
• Obesity is a risk factor for both gallstone formation and severity of acute cholangitis 1
• For patients with severe acute cholangitis, surgical biliary drainage should be avoided 1
• In patients with biliary sepsis, biliary decompression with placement of internal/external drain can be lifesaving 1

Treatment Efficacy

• Laparoscopic cholecystectomy has largely replaced open cholecystectomy as the standard of care 1
• ERCP use for choledocholithiasis has increased from 75.2% to 96.1% of cases 1
• Endoscopic sphincterotomy carries a 6-10% major complication rate, increasing to 19% in elderly patients 1

By following this diagnostic and treatment algorithm, clinicians can effectively manage patients with cholelithiasis and its complications, improving outcomes and reducing morbidity and mortality.