Gallstone Symptoms and Treatment
Symptoms of Gallstone Disease
Most patients with gallstones (approximately 80%) remain asymptomatic throughout their lives, but when symptoms occur, they present as characteristic biliary colic—severe, steady pain in the right upper quadrant and/or epigastrium that radiates to the upper back, is unaffected by position changes or antacids, and typically lasts for hours. 1
Characteristic Pain Pattern
- Biliary colic presents as severe, steady pain with sudden onset, often awakening patients from sleep, located in the right upper quadrant and/or epigastrium 2, 1
- Pain radiates to the upper back in 63% of patients and has a mean intensity of 90/100 on visual analog scale 3
- Episodes last more than one hour in 85% of cases, typically occurring in late evening or at night (77% of attacks) 3
- Pain follows a characteristic pattern with incipient warning pain, a steady state plateau, then gradual subsiding in 90% of patients 3
- Patients experience an urge to walk around during attacks in 71% of cases 3
What Is NOT Gallstone Disease
- Belching, bloating, intolerance of fatty foods, and chronic pain are NOT attributable to gallstone disease 2
- Pain that is present uniformly, frequently comes and goes, and lasts less than 15 minutes does NOT indicate gallstone disease 2
- Dyspeptic symptoms (indigestion, heartburn) are common in gallstone patients but are unrelated to the stones themselves and frequently persist after surgery 4
Complications
- Serious complications include acute cholecystitis, acute pancreatitis, common duct obstruction, ascending cholangitis, gallbladder cancer, and gallstone ileus 2
- Symptomatic patients have a 6-10% annual recurrence rate of biliary pain and 2% annual risk of complications 4
- In patients not undergoing cholecystectomy after acute cholecystitis, complication rates are 14%, 19%, and 29% at 6 weeks, 12 weeks, and 1 year respectively 1
Diagnosis
- Ultrasound is the first-line imaging modality with 96% accuracy for gallstone detection 1, 5
- The sonographic Murphy sign (focal tenderness over the gallbladder during ultrasound) helps differentiate acute cholecystitis from uncomplicated gallstones 5
- MRCP has 85-100% sensitivity for detecting choledocholithiasis when bile duct stones are suspected 1, 5
- HIDA scan has higher sensitivity (97%) and specificity (90%) for acute cholecystitis compared to ultrasound 1
Treatment Options
For Symptomatic Gallstones
Laparoscopic cholecystectomy is the definitive treatment for symptomatic gallstones and should be performed early to prevent recurrent biliary colic and life-threatening complications. 1, 5
- Early laparoscopic cholecystectomy (within 7-10 days, ideally within 24 hours of hospital admission) is the standard of care for acute cholecystitis 1
- Cholecystectomy prevents future pain, complications, gallstone recurrence, and gallbladder cancer 2
- For young, low-risk women under 49 years, surgical mortality is extremely low (0.054%) 5, 6
- One-shot antibiotic prophylaxis is recommended if early intervention is performed, with no post-operative antibiotics needed after uncomplicated cholecystectomy 1
Antibiotic Therapy for Acute Cholecystitis
- For immunocompetent, non-critically ill patients: Amoxicillin/Clavulanate 2g/0.2g q8h for 4 days if source control is adequate 1
- For critically ill or immunocompromised patients: Piperacillin/tazobactam 6g/0.75g loading dose then 4g/0.5g q6h (or 16g/2g continuous infusion) for up to 7 days based on clinical response 1
Nonsurgical Options (Limited Role)
Nonsurgical therapies have significant limitations and are only appropriate for highly selected patients who refuse or cannot tolerate surgery.
- Oral bile acids (ursodiol 10 mg/kg/day or chenodeoxycholic acid 15 mg/kg/day) require daily administration for up to 2 years and are limited to cholesterol stones <15mm diameter 2, 6
- Only 20% of cholecystectomy candidates are suitable for bile acid therapy 2
- Stone recurrence occurs in 30% within 2 years and up to 50% within 5 years after dissolution 6
- Nonsurgical therapies neither prevent gallstone recurrence nor prevent gallbladder cancer 2
- Extracorporeal shock-wave lithotripsy combined with bile acids achieves 80% dissolution for single stones <30mm but only 40% for multiple stones 7
For Asymptomatic Gallstones
- Expectant management is recommended for asymptomatic cholelithiasis, with surgery reserved only for those who become symptomatic or have specific high-risk conditions 1
- Asymptomatic patients develop biliary pain at a rate of 1-4% annually 1, 8
- Approximately 30% of patients with a first episode of biliary pain may not experience additional episodes even with prolonged follow-up 5
Critical Pitfalls to Avoid
- Do not attribute non-specific symptoms like indigestion, flatulence, heartburn, bloating, or belching to gallstones, as these are unlikely to resolve with cholecystectomy and may lead to unnecessary surgery 5
- Do not delay appropriate imaging, as complications (acute cholecystitis, cholangitis, biliary pancreatitis) can be life-threatening 5
- Do not rely solely on absence of sonographic Murphy sign to rule out acute cholecystitis if the patient received pain medication prior to imaging 5
- Watchful waiting carries the risk of requiring intervention when the patient is older and frailer, with higher associated morbidity and mortality 2