Gall stones disease: Clinical Practice Guideline

• Clinical presentation: majority of patients are asymptomatic (approximately 15-25% will be symptomatic after 10 to 15 years of follow-up)
• Symptoms of biliary colic: intense but dull RUQ, epigastric or less frequently substernal pain, may radiate to the back. Pain is associated with fatty meals, vomiting, nausea and/or sweating. Pain often constant but can be colicky.
• Pathophysiology: neuronal or hormonal stimulation of the gallbladder → contraction → stone pushed against outlet or cystic duct → ↑ intra-gallbladder pressure → pain (Murphy's sign = Pushing/Palpating of the RUQ during inspiration leads to respiratory arrest)

Investigation

• Bloods: CBC, Bilirubin, LFT (ALT, AST, ALP), Gamma glutamyl transferase (GGT), Amylase, Lipid profiles
• Imaging: first-line ultrasound abdomen (gallstones are echogenic with shadows)
• Other modalities: abdominal X-ray → may show calcified gallstones

Management

• Gallstones present + asymptomatic → no treatment required, advice given regarding complications and lifestyle modifications
• Gallstones present + symptomatic → advise surgery
  • Biliary colic → elective laparoscopic cholecystectomy
  • Acute cholecystitis
    • If presents within 72 hrs → laparoscopic cholecystectomy
    • If presents > 72 hrs → may consider IV antibiotic treatments until stabilise before laparoscopic cholecystectomy
  • Ascending cholangitis
    • Treating sepsis (IV fluids and antibiotics)
    • Biliary drainage e.g. ERCP or percutaneous transhepatic cholangiography
    • Management of underlying cause: elective laparoscopic cholecystectomy
• Consider open instead of laparoscopic cholecystectomy if
  • Patient needs an open laparotomy for other indication(s) at the same time
  • Patient has complicated pathology e.g., acute gangrenous cholecystitis, acute empyema, or liver cirrhosis

Reference:

• The Royal College of Surgeons of Thailand
• UpToDate - Gallstone Diseases