What is cholelithiasis?

What is Cholelithiasis?

Cholelithiasis is the presence of gallstones (biliary calculi) in the gallbladder, a common disorder affecting approximately 10-20% of the adult population in Western countries. 1, 2

Epidemiology and Risk Factors

• Prevalence increases with age: approximately 20% of adults over 40 years and 30% of those over 70 have gallstones 2
• Female predominance during reproductive years with a 4:1 female-to-male ratio, narrowing to near equality in older populations 2
• Geographic variation exists: prevalence ranges from 3-15% in Asia, is nearly non-existent (<5%) in Africa, and 4.21-11% in China 1
• Risk factors include: obesity, diabetes mellitus, estrogen exposure, pregnancy, increasing parity, hemolytic diseases, and cirrhosis 3, 2

Types of Gallstones

Gallstones are classified into three compositional types: cholesterol stones, mixed stones, and pigment stones based on gross and compositional analysis 2

Clinical Presentation

Asymptomatic Cholelithiasis

• Approximately 50-70% of patients with gallstones are asymptomatic at diagnosis, and an estimated 80% remain asymptomatic throughout their lives 1, 4
• The natural course is benign with progression from asymptomatic to symptomatic disease occurring in only 10-25% of cases 4
• Most patients rarely develop complications without first experiencing at least one episode of biliary pain 4

Symptomatic Cholelithiasis

• Classic biliary pain presents as right upper quadrant or epigastric pain occurring 30-60 minutes after meals 2
• Classical biliary pain occurs in the minority of patients; more commonly, symptomatology is ambiguous 1
• Atypical dyspeptic symptoms include indigestion, flatulence, heartburn, bloating, belching, and nausea, which are less likely to resolve following cholecystectomy 1, 5
• Physical examination findings include a positive Murphy's sign (focal tenderness upon palpation of the right upper quadrant) 1, 3
• Referred pain to the right supraclavicular region and/or shoulder may occur 3

Diagnostic Approach

• Ultrasound is the first-choice imaging investigation for suspected cholelithiasis due to its low cost, lack of invasiveness, no radiation exposure, better availability, and high accuracy (96%) for detecting gallstones 1, 2
• Ultrasound findings include visualization of gallstones, differentiation from gallbladder sludge, polyps, or masses 1
• Radionuclide cholescintigraphy (HIDA scan) can be useful when diagnosis is uncertain, though not universally recommended 5, 2
• Laboratory tests such as white blood cell count, liver enzymes, amylase, and lipase may assist in diagnosis but are not definitive 3

Complications

Cholelithiasis can lead to several serious complications 2:

• Acute cholecystitis develops in 1-3% of patients with symptomatic gallstones 1
• Choledocholithiasis (common bile duct stones) occurs in 3-10% of patients undergoing cholecystectomy 2
• Cholangitis (inflammation of the bile duct) 3
• Gallstone pancreatitis 2
• Gallstone ileus 2

Management Principles

Asymptomatic Cholelithiasis

• Expectant management is recommended for the vast majority of asymptomatic patients, with surgery reserved only for those who become symptomatic or have certain high-risk conditions 1, 5, 4
• Prophylactic cholecystectomy is indicated for specific high-risk subgroups: patients with large stones (>2.5 cm), congenital hemolytic anemia, nonfunctioning gallbladder, or incidentally during other abdominal operations 5, 2

Symptomatic Cholelithiasis

• Cholecystectomy remains the treatment of choice for all patients with symptomatic gallstones, except those too ill to undergo surgery 6, 2
• Early laparoscopic cholecystectomy (within 7 days of symptom onset) is the definitive treatment, offering shorter recovery time and hospitalization compared to delayed approaches 1, 5
• Referral to a surgeon and/or gastroenterologist within 2 weeks of initial presentation is recommended regardless of severity or frequency of symptoms 3

Alternative Therapies

• Oral bile acid therapy (ursodiol at 8-10 mg/kg/day) may be considered for carefully selected patients with small (<20 mm), radiolucent, cholesterol-rich stones, achieving approximately 30% complete dissolution after up to 2 years 5
• Extracorporeal shock-wave lithotripsy (ESWL) combined with oral bile acid therapy is best suited for solitary radiolucent stones smaller than 2 cm 5

Important Clinical Caveats

• Elderly patients and those with severe systemic disease have dramatically increased surgical mortality, requiring careful risk-benefit assessment 5
• Lack of physical examination findings does not rule out cholelithiasis 3
• Post-cholecystectomy syndrome can occur with symptoms including abdominal pain, bloating, diarrhea, and dyspepsia 5