What is cholelithiasis?

Cholelithiasis: Definition and Management

Cholelithiasis is the formation of gallstones in the gallbladder, affecting approximately 10-20% of the general population with a higher prevalence in women, older adults, and those with certain risk factors. 1

What Are Gallstones?

Gallstones are solid concretions that form in the gallbladder from bile components. They can be classified into three main types:

• Cholesterol stones: Most common type (approximately 80% of gallstones)
• Mixed stones: Contain both cholesterol and pigment components
• Pigment stones: Primarily composed of bilirubin calcium salts

Epidemiology

• Affects 10-20% of people in Western countries 2
• 50-70% of people with gallstones are asymptomatic at diagnosis 2
• Higher prevalence in:
  • Women (female-to-male ratio of 4:1 during reproductive years) 3
  • Adults over 40 years (20% affected) 3
  • Adults over 70 years (30% affected) 3
  • Pregnant women and those with increasing parity 1
  • Obese individuals 1

Natural History

• 80% of patients with gallstones remain asymptomatic throughout their lives 4
• Only 10-25% of asymptomatic cases progress to symptomatic disease 2
• Most patients develop biliary pain ("colic") before developing complications 2
• Approximately 35% of untreated patients eventually develop complications or recurrent symptoms requiring cholecystectomy 3

Clinical Presentation

Asymptomatic Cholelithiasis

• No symptoms; typically discovered incidentally during imaging for other conditions
• Generally managed conservatively with observation (expectant management) 4

Symptomatic Cholelithiasis

• Classic presentation: Right upper quadrant pain, often after fatty meals
• Pain may radiate to the right shoulder or supraclavicular region
• Associated symptoms: nausea, vomiting, dyspepsia
• Physical examination may reveal tenderness in the right upper quadrant (positive Murphy's sign) 1

Complications of Cholelithiasis

If left untreated, cholelithiasis can lead to several complications:

1. Acute cholecystitis: Inflammation of the gallbladder
2. Choledocholithiasis: Stones in the common bile duct
3. Cholangitis: Infection of the bile ducts
4. Gallstone pancreatitis: Inflammation of the pancreas due to stone obstruction
5. Gallstone ileus: Intestinal obstruction due to a large gallstone
6. Secondary biliary cirrhosis: Long-term bile duct obstruction leading to liver damage 5

Diagnosis

• Ultrasonography: Gold standard for diagnosis with 90-95% sensitivity 3
• Laboratory tests: May show elevated white blood cell count, liver enzymes, amylase, and lipase in complicated cases 1
• Additional imaging: MRCP, ERCP, or cholescintigraphy (HIDA scan) may be used in certain cases 6

Management

Asymptomatic Gallstones

• Expectant management is recommended for most patients 4
• Selective cholecystectomy only for high-risk groups:
  • Large stones (>2.5 cm)
  • Patients at risk for gallbladder cancer
  • During other abdominal surgeries 4, 3

Symptomatic Gallstones

• Laparoscopic cholecystectomy is the standard treatment 4
• Early cholecystectomy (within 10 days of symptom onset) is preferable to delayed intervention 4
• Medical management options:
  • Low-fat diet to reduce gallbladder stimulation 6
  • Ursodiol (ursodeoxycholic acid): May dissolve small, uncalcified cholesterol stones
    • Dissolution rates of approximately 30% for uncalcified stones <20mm 7
    • Stone recurrence after dissolution: 30% within 2 years, up to 50% within 5 years 7

Common Bile Duct Stones (Choledocholithiasis)

• ERCP with sphincterotomy and stone extraction is the first-line therapeutic procedure 6
• Success rate of approximately 90% 6
• Alternative approaches for difficult cases:
  • Percutaneous transhepatic approach
  • Rendezvous technique combining percutaneous and endoscopic approaches 6

Key Points for Clinical Practice

• Most gallstones (80%) remain asymptomatic and do not require intervention 4
• The presence of biliary pain is the most important factor in determining the need for intervention
• Laparoscopic cholecystectomy is the definitive treatment for symptomatic gallstones 4
• Patients with asymptomatic gallstones should be educated about potential symptoms that warrant medical attention
• Ursodiol therapy may be considered for selected patients who are poor surgical candidates, but has limitations including stone recurrence after treatment cessation 7

Pitfalls to Avoid

• Don't assume that all abdominal pain in patients with gallstones is due to the gallstones; atypical symptoms like dyspepsia, flatulence, and bloating are less likely to resolve after cholecystectomy 4
• Avoid routine cholecystectomy for all patients with asymptomatic gallstones, as this is too aggressive 2
• Don't delay surgical intervention in patients with acute cholecystitis; laparoscopic cholecystectomy is more successful when performed within 3 days of symptom onset 3
• Be aware that gallstone dissolution with ursodiol has limitations: it works only for uncalcified cholesterol stones, takes months to years, and has high recurrence rates 7