What is the management plan for a patient with gallbladder pathology, such as gallstones or signs of inflammation, shown on a computed tomography (CT) scan of the abdomen?

Management of Gallbladder Pathology on CT Scan

For patients with gallbladder pathology identified on CT scan, management should be based primarily on whether the condition is symptomatic or asymptomatic, with laparoscopic cholecystectomy being the treatment of choice for symptomatic gallstones. 1, 2

Asymptomatic Gallstones

• Expectant management is recommended for patients with asymptomatic gallstones due to their benign natural history and low risk of developing complications 1
• Only 10-25% of asymptomatic gallstones progress to symptomatic disease 3
• Most patients with gallstone-related complications have at least one episode of biliary pain before developing complications 3

Exceptions for asymptomatic patients:

• Patients with high risk for gallbladder cancer:
  • Calcified gallbladders
  • Large stones (>3 cm)
  • New World Indians (e.g., Pima Indians) 1
• Patients undergoing major upper abdominal surgery for other conditions 4

Symptomatic Gallstones

Diagnostic Evaluation

• Initial evaluation should include:
  • CBC to evaluate for leukocytosis
  • LFTs to evaluate for liver abnormalities
  • Pancreatic enzymes to evaluate for pancreatic abnormalities 2
• Imaging:
  • Ultrasound is the initial imaging of choice (96% accuracy for detecting gallstones) 2
  • MRI with MRCP is a second-line option for better visualization of biliary structures 2
  • Cholescintigraphy (HIDA scan) is appropriate for suspected acute cholecystitis with equivocal ultrasound results 2

Treatment Algorithm

1. Uncomplicated symptomatic gallstones:

   • Laparoscopic cholecystectomy is the preferred treatment 1, 4
   • Early cholecystectomy (within 7-10 days of symptom onset) is recommended 1
   • One-shot antibiotic prophylaxis if early intervention; no post-operative antibiotics needed 1

2. Complicated gallstones (acute cholecystitis):

   • Laparoscopic cholecystectomy with antibiotic therapy 1
   • Antibiotic therapy for 4 days in immunocompetent, non-critically ill patients if source control is adequate 1
   • Antibiotic therapy up to 7 days based on clinical conditions and inflammation indices in immunocompromised or critically ill patients 1

3. Gallstones with common bile duct stones:

   • Patients with gallstones and common bile duct stones treated by endoscopic sphincterotomy should undergo cholecystectomy 4
   • Laparoscopic cholecystectomy with laparoscopic common bile duct exploration or with intraoperative endoscopic sphincterotomy is preferred for obstructive jaundice caused by common bile duct stones 4

4. Acute gallstone pancreatitis:

   • Laparoscopic cholecystectomy during index admission is recommended in mild acute gallstone pancreatitis 1
   • When ERCP and sphincterotomy are performed during index admission, same-admission cholecystectomy is still advised due to increased risk for other biliary complications 1
   • In acute gallstone pancreatitis with peripancreatic fluid collections, cholecystectomy should be deferred until fluid collections resolve or stabilize and acute inflammation ceases 1

Special Considerations

Gallbladder Polyps

• Conservative management with follow-up ultrasound for polyps <6 mm 2
• Surgical consultation indicated if:
  • Polyp increases to ≥15 mm on future imaging
  • Polyp grows by ≥4 mm within a 12-month period
  • Symptoms significantly impact quality of life despite ruling out other causes 2

Critically Ill or Immunocompromised Patients

• For complicated cholecystitis:
  • Piperacillin/tazobactam 6 g/0.75 g LD then 4 g/0.5 g q6h or 16 g/2 g by continuous infusion 1
  • For beta-lactam allergy: Eravacycline 1 mg/kg q12h 1
• Cholecystostomy may be an option for acute cholecystitis in patients with multiple comorbidities unfit for surgery 1

Pitfalls and Caveats

• Not all right upper quadrant pain is due to gallbladder disease - gastroduodenal pathologies such as peptic ulcers and gastritis are common in patients with asymptomatic gallstones 5
• CT scan may miss uncomplicated gallstones, early or mild cholecystitis, biliary colic without inflammation, or stones in the cystic duct or common bile duct 2
• For women of reproductive age, beta human chorionic gonadotropin testing should be performed before imaging 2
• Patients who have ongoing signs of infection beyond 7 days of antibiotic treatment warrant further diagnostic investigation 1