What is Cholelithiasis?
Cholelithiasis is the presence of gallstones in the gallbladder, a highly prevalent condition affecting approximately 10-20% of adults in Western countries, with the majority (50-70%) remaining asymptomatic at the time of diagnosis. 1
Epidemiology and Risk Factors
- Prevalence increases with age: approximately 20% of adults over 40 years and 30% of those over 70 have biliary calculi 2
- Gender disparity: women are affected 4 times more frequently than men during reproductive years, with the ratio narrowing to near equality in older populations 2
- Approximately 500,000 cholecystectomies are performed annually in the United States for gallstone-related disease 1
Types of Gallstones
Gallstones can be classified compositionally into three main categories 2:
- Cholesterol stones: the most common type in Western populations
- Mixed stones: containing both cholesterol and pigment components
- Pigment stones: associated with hemolytic disorders and cirrhosis
Clinical Presentation
Asymptomatic Cholelithiasis
- The majority (50-70%) of patients with gallstones are asymptomatic at diagnosis and have a benign natural course 3
- Only 10-25% of asymptomatic patients progress to symptomatic disease, and most rarely develop complications without first experiencing at least one episode of biliary pain 3
Symptomatic Cholelithiasis
Classic presentation includes right upper quadrant pain occurring 30-60 minutes after meals (biliary colic), often with referred pain to the right shoulder or supraclavicular region, accompanied by nausea and vomiting. 4, 2
- Positive Murphy's sign (pain elicited upon palpation of the right upper quadrant during deep inspiration) is a characteristic physical examination finding 4
- Lack of physical examination findings does not rule out cholelithiasis 4
Diagnostic Approach
Transabdominal ultrasound is the gold standard diagnostic test for cholelithiasis, with 90-95% sensitivity for detecting gallstones. 1, 2
- Ultrasound findings include gallstones, pericholecystic fluid, distended gallbladder, edematous gallbladder wall, and sonographic Murphy's sign 1
- Laboratory tests (white blood cell count, liver enzymes, alkaline phosphatase, bilirubin, amylase, lipase) may assist in diagnosis but are not definitive 4
Complications
Approximately 18% of adults undergoing cholecystectomy have choledocholithiasis (common bile duct stones), which can lead to biliary obstruction 1, 5
Other complications include 2:
- Acute cholecystitis: inflammation of the gallbladder
- Cholangitis: inflammation and infection of the bile ducts
- Gallstone pancreatitis: obstruction of the pancreatic duct
- Gallstone ileus: intestinal obstruction from a large stone
Common Pitfalls
- Atypical dyspeptic symptoms (indigestion, flatulence, heartburn, bloating, belching) are less reliably associated with gallstone disease and less likely to resolve following cholecystectomy compared to classic biliary pain 1, 6
- Asymptomatic gallstones detected incidentally should not routinely prompt cholecystectomy, as approximately 70-80% of patients remain asymptomatic throughout their lives 3
- Elevated alkaline phosphatase without biliary ductal dilatation on ultrasound suggests intrahepatic cholestasis rather than gallstone disease 1