How should I evaluate and manage a patient with suspected gallstones?

Evaluation of Gallstones

Initial Diagnostic Approach

Begin with trans-abdominal ultrasound and liver function tests for all patients with suspected gallstone disease, regardless of symptom presentation. 1

First-Line Imaging: Trans-Abdominal Ultrasound

• Ultrasound is the investigation of choice for suspected gallstone disease, with sensitivity of 73% and specificity of 91% for detecting stones 1
• Look specifically for: gallstones in the gallbladder, bile duct dilation, gallbladder wall thickening (>3mm), pericholecystic fluid, and Murphy's sign on ultrasound examination 1
• Normal ultrasound does NOT exclude gallstone disease if clinical suspicion remains high 1

Essential Laboratory Tests

• Obtain complete liver function tests including: bilirubin, alkaline phosphatase, ALT, AST 1
• Bilirubin >22.23 μmol/L has 84% sensitivity and 91% specificity for common bile duct stones 1
• Alkaline phosphatase >125 IU/L has 92% sensitivity but only 79% specificity 1
• Elevated bilirubin >twice normal limit is highly specific (97%) but poorly sensitive (42%) 1

Clinical Presentations Requiring Investigation

Investigate for gallstones when patients present with:

• Epigastric or right upper quadrant pain, especially if severe, steady, lasting hours, and radiating to the upper back 1, 2
• Pain associated with jaundice and/or fever (suggests cholangitis or cholecystitis) 1
• Acute pancreatitis (gallstones cause up to 50% of cases) 1
• Atypical but persistent abdominal symptoms despite alternative management 1

Risk Stratification for Common Bile Duct Stones

After initial ultrasound and liver function tests, stratify patients by probability of common bile duct stones:

Intermediate Probability Patients

• Proceed to MRCP or endoscopic ultrasound (EUS) as both are highly accurate for identifying common bile duct stones 1
• MRCP is the predominant choice, with selection between MRCP and EUS based on availability, local expertise, and patient suitability 1
• MRCP shows bile as bright signal with stones appearing as dark filling defects 1
• EUS shows stones as hyperechoic foci with acoustic shadowing 1

High Probability Patients

• Consider proceeding directly to ERCP for both diagnosis and therapeutic intervention 1

Management Based on Symptom Status

Asymptomatic Gallstones

Expectant management is recommended for asymptomatic gallstones in most patients 1

• Annual risk of developing symptoms is only 2-5% initially, with cumulative 5-year risk of 7-27% 3, 2, 4
• Risk of complications is <1% annually 2
• Exceptions requiring prophylactic cholecystectomy: calcified gallbladder, stones >3 cm, high-risk populations (e.g., Native Americans) 1

Symptomatic Gallstones

Offer definitive treatment with laparoscopic cholecystectomy for symptomatic disease 1

• Symptomatic patients have 6-10% annual recurrence of symptoms and 2% annual complication rate if untreated 2
• Laparoscopic cholecystectomy is preferred over open cholecystectomy when skilled surgeon available 1
• For acute cholecystitis: early cholecystectomy (within 7-10 days) with single-shot antibiotic prophylaxis 1

Common Bile Duct Stones

Patients with confirmed common bile duct stones should be offered stone extraction 1

• Conservative management results in 25.3% unfavorable outcomes (pancreatitis, cholangitis, obstruction) versus 12.7% with stone extraction (OR 0.44) 1
• Benefits persist even for stones <4 mm: 8.9% complications with extraction versus 15.9% conservative (OR 0.52) 1
• For acute pancreatitis with ongoing bile duct obstruction/cholangitis: ERCP with sphincterotomy within 24-72 hours 5

Common Pitfalls to Avoid

• Do not rely solely on normal ultrasound or liver function tests to exclude gallstone disease when clinical suspicion is high 1
• Do not assume dyspeptic symptoms (bloating, belching, food intolerance) are caused by gallstones—these symptoms are common in the general population and frequently persist after cholecystectomy 2
• Do not leave common bile duct stones untreated, even if small or asymptomatic, as complication rates are significant 1
• Be aware that CT has limited sensitivity for gallstones compared to ultrasound; use CT primarily when complications are suspected 1

Alternative Medical Therapy (Limited Role)

Medical dissolution therapy with ursodeoxycholic acid (8-10 mg/kg/day) is reserved for:

• Patients unfit for surgery with radiolucent cholesterol stones <6mm and patent cystic duct 3, 6
• Recurrence rate after dissolution is approximately 50%, limiting long-term effectiveness 6