What factors should be evaluated in a patient with cholelithiasis, considering demographics, medical history, and symptoms?

Evaluation of Cholelithiasis

Begin with a detailed patient history focusing on symptom characterization, followed by liver biochemical tests (ALT, AST, bilirubin, ALP, GGT) and abdominal ultrasonography to establish diagnosis and assess for complications. 1

Clinical History Assessment

Symptom Characterization

• Document the presence and pattern of biliary pain: right upper quadrant or epigastric pain occurring 30-60 minutes after meals, with or without radiation to the right shoulder or supraclavicular region 2, 3
• Assess for complications: fever with rigors suggests cholangitis (particularly with choledocholithiasis), though fever can also occur with alcoholic disease or rarely viral hepatitis 1
• Distinguish symptomatic from asymptomatic disease: classical biliary pain occurs in the minority; most patients present with ambiguous symptoms including indigestion, flatulence, heartburn, bloating, belching, and nausea 1

Medical and Surgical History

• Prior biliary surgery: significantly increases likelihood of biliary obstruction 1
• Medication review: document all medications, herbal medicines, vitamins, and supplements taken within 6 weeks of presentation, as these may cause drug-induced cholestasis 1
• Occupational history: essential for identifying potential toxic exposures 1

Risk Factor Assessment

• Demographics: women are affected 4:1 during reproductive years; risk increases with age (20% over age 40,30% over age 70) 3
• Metabolic factors: obesity, diabetes mellitus, pregnancy, increasing parity 2, 3
• Hemolytic diseases: 39% of pediatric cholelithiasis cases are associated with hemolytic conditions 4
• Family history: suggests hereditary cholestatic disorders 1
• Special populations: pregnancy, childhood, liver transplantation, HIV-infection require specific investigations 1

Laboratory Evaluation

Initial Biochemical Tests

• Obtain liver biochemical panel in all patients: ALT, AST, bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT) 1, 5
• Interpret cholestatic markers: ALP >1.5 times upper limit of normal (ULN) and GGT >3 times ULN warrant diagnostic work-up 1
• Assess for choledocholithiasis risk: elevation of liver enzymes and/or bilirubin alone is insufficient to identify common bile duct stones; further testing is required 1

Risk Stratification for Common Bile Duct Stones

High-risk patients (>50% probability) should proceed directly to ERCP, intraoperative cholangiography, or laparoscopic ultrasound 5:

• CBD stone visualized on ultrasound 5
• Total bilirubin >4 mg/dL 5
• CBD diameter >6 mm (with gallbladder in situ) 5
• Bilirubin 1.8-4 mg/dL 5

Moderate-risk patients require confirmatory imaging with MRCP (sensitivity 93%, specificity 96%), endoscopic ultrasound (sensitivity 95%, specificity 97%), intraoperative cholangiography (sensitivity 87%, specificity 99%), or laparoscopic ultrasound (sensitivity 87%, specificity 100%) 5

Imaging Studies

Abdominal Ultrasonography

• First-line imaging modality: 90-95% sensitive for detecting gallstones, non-invasive, portable, and relatively inexpensive 1, 3
• Assess for biliary dilatation: identifies dilated intra- and extrahepatic ducts to differentiate obstructive from non-obstructive disease 1
• Evaluate for complications: wall thickening, pericholecystic fluid, and sonographic Murphy's sign suggest acute cholecystitis 3
• Limitations: operator-dependent; may miss bile duct abnormalities such as sclerosing cholangitis; only 50-63% sensitive for choledocholithiasis 1, 5

Additional Imaging When Indicated

• Do not repeat ultrasound if initial study is negative but clinical suspicion for CBD stones remains high: proceed directly to MRCP or endoscopic ultrasound for moderate-risk patients 6
• MRCP: sensitivity 77-93% for choledocholithiasis, more sensitive than CT or transabdominal ultrasound for ductal calculi 5
• Hepatobiliary scintigraphy (HIDA scan): 97% sensitivity for acute cholecystitis when ultrasound is equivocal 6, 3

Physical Examination Findings

Key Examination Elements

• Murphy's sign: right upper quadrant tenderness elicited upon palpation, though lack of physical findings does not rule out cholelithiasis 2
• Assess for jaundice: suggests biliary obstruction or cholangitis 2
• Document extrahepatic diseases: may provide clues to underlying cholestatic disorders 1

Special Considerations

Asymptomatic Cholelithiasis

• Expectant management is appropriate for most patients: 80% remain asymptomatic throughout their lives; only 10-25% progress to symptomatic disease 1, 7
• Prophylactic cholecystectomy is indicated only in specific high-risk subgroups: large stones >2.5 cm, congenital hemolytic anemia, nonfunctioning gallbladder, or during concurrent abdominal surgery 7, 3
• CCK-cholescintigraphy has no role: insufficient evidence to predict which asymptomatic patients will develop symptoms 1

Elderly Patients

• Apply same risk stratification for choledocholithiasis: but emphasize avoiding unnecessary procedures given higher complication rates 1, 5
• Early laparoscopic cholecystectomy is safe and feasible: should be performed within 10 days of symptom onset, preferably within 3 days for acute cholecystitis 1, 3
• Conversion to open surgery may be predicted by: fever, leukocytosis, elevated serum bilirubin, and extensive prior upper abdominal surgery 1

Common Pitfalls to Avoid

• Do not rely on isolated GGT elevation: has little specificity for cholestasis and may result from alcohol or drug-induced enzyme induction 1
• Do not assume atypical dyspeptic symptoms will resolve with cholecystectomy: indigestion, flatulence, heartburn, bloating, and belching are less likely to improve after surgery 1
• Do not repeat transabdominal ultrasound to "rule out" CBD stones: sensitivity is only 73%; proceed to MRCP or endoscopic ultrasound instead 6