What is the best course of treatment for a patient with gallbladder stones, altered Liver Function Tests (LFTs), and symptoms of biliary colic, including frequent urination after eating and generalized stomach pain?

Laparoscopic Cholecystectomy Within 7-10 Days

This patient requires early laparoscopic cholecystectomy within 7-10 days of symptom onset, as they have symptomatic cholelithiasis with altered liver function tests suggesting possible biliary obstruction or inflammation. 1

Immediate Diagnostic Workup

Before proceeding to surgery, you must clarify the nature of the altered LFTs and rule out common bile duct (CBD) obstruction:

• Order MRCP (magnetic resonance cholangiopancreatography) immediately to evaluate for CBD stones, given the altered LFTs which may indicate biliary obstruction. 1
• The altered LFTs are a red flag that distinguishes this from simple biliary colic—this suggests either CBD stones, cholangitis, or acute cholecystitis with inflammation. 1
• Ultrasound should have already been performed as the initial investigation of choice, but if not done, obtain it urgently. 1

Addressing the Clinical Presentation

The patient's symptoms require clarification:

• "Going to the bathroom more often after eating" is NOT a typical biliary symptom—this may represent diarrhea (which can occur with bile acid malabsorption or other GI pathology) but is not characteristic of gallstone disease. 2
• True biliary colic presents as severe, steady epigastric or right upper quadrant pain lasting 4-6 hours, often radiating to the upper back with nausea—not vague "generalized stomach pain." 2
• Vague symptoms like indigestion, bloating, or generalized discomfort are NOT attributable to gallstones and will not improve with cholecystectomy. 2

However, the altered LFTs override concerns about atypical symptoms—this suggests objective biliary pathology requiring intervention.

Management Algorithm Based on MRCP Findings

If MRCP Shows CBD Stones:

• Perform ERCP with sphincterotomy and stone extraction first, followed by same-admission or early cholecystectomy. 1, 3
• In patients with CBD stones cleared by ERCP, cholecystectomy reduces recurrent biliary events from 24% to 7% and is strongly recommended. 4, 5
• Same-admission cholecystectomy is preferred once the patient is clinically improving to prevent readmission and recurrent complications. 1

If MRCP Shows No CBD Stones:

• Proceed directly to early laparoscopic cholecystectomy within 7-10 days of symptom onset. 1
• Early surgery (within 7-10 days) shortens total hospital stay by approximately 4 days and allows return to work 9 days sooner compared to delayed surgery. 1
• Delaying surgery beyond this window increases technical difficulty and complication rates. 1

Surgical Approach

• Laparoscopic cholecystectomy is the gold standard for symptomatic gallstone disease with altered LFTs, regardless of stone size. 1
• The procedure should be performed by an experienced surgeon, as bile duct injury occurs in 0.4-1.5% of cases. 6
• Conversion to open surgery is not a failure but a valid option when laparoscopic expertise has been maximized or anatomy is unclear. 1

Antibiotic Considerations

• One-shot antibiotic prophylaxis is recommended if this represents uncomplicated cholecystitis with early intervention. 1
• If there are signs of complicated cholecystitis (fever, leukocytosis, persistent pain beyond 6 hours), give antibiotics for 4 days if source control is adequate. 1
• Look specifically for fever, right upper quadrant tenderness, and leukocytosis to distinguish acute cholecystitis from biliary colic. 2

Critical Pitfalls to Avoid

• Do not delay surgery waiting for "typical" biliary colic symptoms—altered LFTs indicate objective pathology requiring intervention regardless of symptom character. 1
• Do not attribute the frequent bathroom visits to gallstones—counsel the patient that this specific symptom will likely not improve with cholecystectomy. 2
• Do not perform cholecystectomy without first ruling out CBD stones with MRCP—operating without clearing CBD stones first can lead to retained stones and recurrent complications. 1, 3
• Approximately 30% of patients with a single episode of biliary pain never have recurrence, but altered LFTs suggest this is not simple biliary colic. 2

Expected Outcomes

• Mortality for laparoscopic cholecystectomy in appropriately selected patients is 0.054% in low-risk women under 49, increasing with age and comorbidities. 6
• Cholecystectomy will resolve biliary colic and prevent complications like cholangitis, acute cholecystitis, and pancreatitis. 1, 3
• The generalized stomach pain and frequent urination may not resolve, as these are atypical symptoms not clearly attributable to gallstones. 2