What is the diagnosis and treatment for Cholelithiasis (Gallstones)?

From the Guidelines

Cholecystectomy, usually performed laparoscopically, is the definitive treatment for symptomatic cholelithiasis, as it provides immediate and definitive surgical treatment after establishing diagnosis and surgical fitness of the patient. The diagnosis of cholelithiasis is made based on clinical features such as right upper quadrant pain, fever, and leukocytosis, and is supported by findings from relevant imaging studies, with abdominal ultrasound being the preferred initial imaging technique 1.

Diagnosis

• The combination of symptoms, signs, and laboratory test results may have better diagnostic accuracy in confirming the diagnosis of acute cholecystitis 1.
• Abdominal ultrasound is the preferred initial imaging technique for patients who are clinically suspected of having acute cholecystitis, due to its lower costs, better availability, lack of invasiveness, and good accuracy for stones 1.
• HIDA scan has the highest sensitivity and specificity for acute cholecystitis, but its use is limited by scarce availability, long execution time, and exposure to ionizing radiation 1.

Treatment

• Laparoscopic cholecystectomy is a safe and effective treatment for acute cholecystitis, and is the first choice for patients with acute cholecystitis where adequate resources and skill are available 1.
• Early laparoscopic cholecystectomy appears to be as safe and effective as delayed laparoscopic cholecystectomy, and may be associated with lower hospital costs, fewer work days lost, and greater patient satisfaction 1.
• Cholecystostomy is a safe and effective treatment for acute cholecystitis in critically ill and/or patients with multiple comorbidities who are unfit for surgery 1.
• Percutaneous cholecystostomy can be considered in the treatment of acute cholecystitis patients who are deemed unfit for surgery, and can be used as a bridge to cholecystectomy in acutely ill patients 1.

Management

• Patients with symptomatic gallstones should be treated with cholecystectomy, usually performed laparoscopically, as soon as possible, but can be performed up to 10 days of onset of symptoms 1.
• Patients should follow a low-fat diet to reduce symptoms while waiting for surgery.
• Pain can be managed with NSAIDs like ibuprofen (400-600mg every 6 hours) or acetaminophen (500-1000mg every 6 hours).
• Patients should seek immediate medical attention for severe abdominal pain, fever, jaundice, or persistent vomiting, as these may indicate complications like cholecystitis, choledocholithiasis, or pancreatitis.

From the Research

Diagnosis of Cholelithiasis (Gallstones)

• The diagnosis of cholelithiasis is typically made based on a combination of clinical, biochemical, and radiological features, including increased serum levels of bilirubin, GOT, GPT, GGT, alkaline phosphatase, presence of jaundice, history of pancreatitis or cholangitis, dilated common bile duct, or common bile duct stones at hepatobiliary ultrasonography 2.
• Imaging studies such as MR-cholangiography or i.v. cholangiography may also be used to diagnose common bile duct stones 2.

Treatment of Cholelithiasis (Gallstones)

• Laparoscopic cholecystectomy has become the treatment of choice for patients with symptomatic cholelithiasis 2, 3, 4.
• For patients with acute cholecystitis, the laparoscopic approach has been shown to be technically feasible and at least equally as safe as the open approach, but conversion to open cholecystectomy remains an important treatment option to secure patient safety in difficult conditions 3.
• Medical treatment is indicated for patients who are not fit or are afraid of surgery, and includes oral bile acids, bile acids as adjuncts to lithotripsy, and contact dissolution using methyltertbutylether 4.
• Simultaneous surgical treatment tactics, such as endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic papillosphincterotomy (EPST) and laparoscopic cholecystectomy (LCE) in a one-stage operation, may be used to treat acute destructive cholecystitis combined with choledocholithiasis 5.
• Laparoscopic cholecystectomy may be beneficial for asymptomatic patients who develop gallstones after bariatric surgery, and has been shown to achieve similar results as those reported in the general population 6.

Treatment Options for Choledocholithiasis

• The management of common bile duct stones remains controversial, with many different surgical strategies available, including laparoscopic common bile duct exploration, sequential endoscopic and laparoscopic treatment, inverted sequential endoscopic-laparoscopic treatment, and combined endoscopic-laparoscopic treatment 2.
• Combined endoscopic-laparoscopic treatment may present more advantages, especially in terms of morbidity, hospital stay, and patient compliance, and may be considered the treatment of choice for patients with cholecystocholedocholithiasis 2.