What are the symptoms and treatment options for gallstones?

Gallstone Symptoms and Treatment

Most patients with gallstones (50-80%) remain asymptomatic throughout their lives and require only expectant management, while symptomatic disease manifests primarily as biliary colic—severe, steady right upper quadrant or epigastric pain lasting hours that often awakens patients from sleep. 1, 2

Clinical Presentation of Symptomatic Gallstones

Classic Biliary Colic

• Severe, steady pain in the right upper quadrant and/or epigastrium that is unaffected by position changes, antacids, or gas passage 3, 4
• Abrupt onset that frequently awakens patients from sleep 4
• Duration of hours up to a full day 4
• Radiation to the upper back with associated nausea 4
• Pain episodes recur with variable frequency from weeks to years 3

Acute Cholecystitis (Complicated Disease)

• Right upper quadrant abdominal pain 3
• Murphy's sign (inspiratory arrest during deep palpation of the right upper quadrant) 3
• Fever 3
• Abdominal tenderness with possible palpable gallbladder mass (indicating complicated disease) 3

Important Clinical Pitfall

Do not attribute non-specific symptoms to gallstones—belching, bloating, fatty food intolerance, heartburn, indigestion, and chronic diffuse pain are NOT caused by gallstones and will not resolve with cholecystectomy. 3, 5, 4 These dyspeptic symptoms persist after surgery in many patients and should not drive treatment decisions. 4

Diagnostic Approach

First-Line Imaging

• Ultrasound is the investigation of choice with 96% accuracy for gallstone detection 3, 2, 5
• Sonographic Murphy's sign helps differentiate acute cholecystitis from uncomplicated stones 5
• Caution: Pain medication prior to imaging can mask the sonographic Murphy's sign 5

Additional Imaging Modalities

• MRCP for suspected common bile duct stones (sensitivity 85-100%, specificity 90%) 3, 2
• CT with IV contrast for complicated cases, though limited sensitivity (~75%) for stone detection 3, 2
• Cholescintigraphy (HIDA scan) has higher sensitivity (97%) and specificity (90%) for acute cholecystitis compared to ultrasound 2

Treatment Algorithm

Asymptomatic Gallstones

Expectant management (observation alone) is recommended as the risks of intervention outweigh benefits in asymptomatic patients. 3, 1, 2

• Annual risk of developing symptoms is only 2-5% in the initial years, with declining rates thereafter 3, 4
• Risk of complications is less than 1% annually 4
• 80% of patients remain asymptomatic throughout their lives 1, 2

Symptomatic Uncomplicated Gallstones (Biliary Colic)

Laparoscopic cholecystectomy is the definitive treatment and should be performed early (within 7-10 days of symptom onset) to prevent recurrent pain and complications. 3, 2, 5, 6

Rationale for Surgery

• Approximately 6-10% of symptomatic patients experience recurrent symptoms annually 4
• 2% develop biliary complications per year 4
• In patients not undergoing cholecystectomy after initial acute cholecystitis, complication rates are 14% at 6 weeks, 19% at 12 weeks, and 29% at 1 year 2
• Surgery offers immediate and permanent stone removal 7
• Mortality for low-risk women under 49 years is extremely low (0.054%) 5, 7

Acute Pain Management

• NSAIDs and spasmolytics are first-line for biliary colic 6
• Opioids for severe acute pain 6

Acute Cholecystitis (Complicated Disease)

Early laparoscopic cholecystectomy (within 7-10 days, ideally within 24 hours of hospital admission) is the standard of care. 3, 6, 8

Surgical Approach

• One-shot antibiotic prophylaxis if early intervention performed 3
• No post-operative antibiotics needed after early uncomplicated cholecystectomy 3
• Open cholecystectomy as alternative if laparoscopic approach not feasible 3

Antibiotic Therapy for Complicated Cases

For immunocompetent, non-critically ill patients with adequate source control:

• Amoxicillin/Clavulanate 2g/0.2g q8h 3
• Duration: 4 days if source control adequate 3
• Beta-lactam allergy: Eravacycline 1 mg/kg q12h or Tigecycline 100 mg loading dose then 50 mg q12h 3

For critically ill or immunocompromised patients:

• Piperacillin/tazobactam 6g/0.75g loading dose then 4g/0.5g q6h (or 16g/2g continuous infusion) 3
• Duration: up to 7 days based on clinical response and inflammatory markers 3
• Beta-lactam allergy: Eravacycline 1 mg/kg q12h 3

Alternative for High-Risk Surgical Patients

• Cholecystostomy may be considered for patients with multiple comorbidities unfit for surgery who fail antibiotic therapy, though it is inferior to cholecystectomy for critically ill patients 3
• Antibiotic therapy for 4 days with cholecystostomy 3

Medical Dissolution Therapy (Limited Role)

Medical therapy with ursodiol is NOT recommended for symptomatic stones as it requires months of therapy, fails in many patients, and has 50% recurrence rates within 5 years. 7, 9

Strict Selection Criteria (if considered)

• Stones must be radiolucent (cholesterol-rich) 7, 9
• Cystic duct must be patent (confirmed by gallbladder opacification on oral cholecystography) 9
• Best for stones <6mm diameter 9
• Dosing: Ursodeoxycholic acid 10 mg/kg/day or chenodeoxycholic acid 15 mg/kg/day 9

Limitations

• Complete dissolution does not occur in all patients 7
• Stone recurrence in up to 50% within 5 years 7
• Requires months of therapy 7

Special Populations

Pregnancy:

• Laparoscopic cholecystectomy safest during second trimester 5
• Conservative management has 60% recurrence rate of biliary symptoms 5

Rapid Weight Loss (Bariatric Surgery/Very Low-Calorie Diet):

• Ursodiol 600 mg/day reduces gallstone formation from 23% to 1-3% during rapid weight loss 7

Critical Complications Requiring Urgent Intervention

• Acute cholangitis: Immediate antibiotics and endoscopic intervention 8
• Biliary pancreatitis with ongoing obstruction: ERCP and sphincterotomy within 24-72 hours 8
• Common bile duct stones: Primarily treated endoscopically 6

Key Clinical Pitfalls to Avoid

• Do not delay imaging when complications are suspected—acute cholecystitis, cholangitis, and biliary pancreatitis are life-threatening 5
• Do not perform cholecystectomy for non-specific dyspeptic symptoms without documented biliary colic 5
• Do not offer medical dissolution therapy as first-line for symptomatic stones—surgery is definitive 7, 9
• Patients with ongoing infection beyond 7 days of antibiotics warrant diagnostic investigation 3