- 1 Introduction
- 2 Risk Factors
- 3 Clinical Features
- 4 Differential Diagnosis
- 5 Investigations
- 6 Management
- 7 Complications
- 8 Key Points
Gallstone disease is prevalent in Western populations (10-14% will develop gallstones), yet most will remain asymptomatic. Each year between 1-4% will develop symptoms secondary to their gallstones.
Bile is formed from cholesterol, phospholipids, and bile pigments (products of haemoglobin metabolism). It is stored in the gallbladder, before passing into the duodenum upon gallbladder stimulation. Gallstones form as a result of supersaturation of the bile.
There are three main types of gallstones:
Cholesterol stones – composed purely of cholesterol, from excess cholesterol production
- There is a well recognised link between poor diet, obesity, and cholesterol stones
Pigment stones – composed purely of bile pigments, from excess bile pigments production
- Commonly seen in those with known haemolytic anaemia
- Mixed stones – comprised of both cholesterol and bile pigments
Classically the common risk factors for gallstone disease are described as the 5 F’s of Fat, Female, Fertile, Forty, and Family history.
Other recognised risk factors include pregnancy and oral contraceptives*, haemolytic anaemia, and malabsorption (e.g. ileal resection or Crohn’s disease).
*Oestrogen causes more cholesterol to be secreted into bile
Studies have shown for those who are symptomatic, over 50% will present as biliary colic and 35% as an acute cholecystitis. For asymptomatic gallstones, these are often simply picked up incidentally on scans, most commonly a trans-abdominal ultrasound scan (Fig. 2).
Biliary colic occurs when the gallbladder neck becomes impacted by a gallstone. There is no inflammatory response, yet the contraction of the gallbladder against the occluded neck will result in pain.
The pain is typically sudden, dull, and colicky (comes and goes) in nature. It is often focused in the right upper quadrant although it may radiate to the epigastrium and/or back. The pain may be precipitated by the consumption of fatty foods* and the patient often complains of nausea and vomiting. In general, once pain relief has been started, symptoms often settle quickly.
*Fatty acids stimulate the duodenum endocrine cells to release cholecystokinin (CCK), which in turn stimulates contraction of the gallbladder.
The symptoms of acute cholecystitis are often similar to that of someone with biliary colic, although the pain may be constant, persistent despite pain relief, and is often associated with signs of inflammation (e.g fever, raised WCC). The patient may also demonstrate some derangement of their liver function tests.
When examining any patient with suspected gallbladder pathology, it is important to check for signs of inflammation (e.g. tachycardia, pyrexia), signs of peritonitis or perforation, and signs of jaundice or hepatomegaly. Patients with acute cholecystitis will be tender in the RUQ and will likely demonstrate a positive Murphy’s sign.
Whilst applying pressure in the RUQ, ask the patient to inspire. Murphy’s sign is positive when there is a halt in inspiration due to pain, indicating an inflamed gallbladder. This can be achieved more accurately with an ultrasound, namely the sonographic Murphy sign.
There are a wide variety of pathologies that can present with RUQ pain. However, differentials to consider for any suspected gallbladder disease include gastro-oesophageal reflux disease, peptic ulcer disease, acute pancreatitis, or inflammatory bowel disease.
Urinalysis (including a pregnancy test if female) should be performed to exclude any renal and tubo-ovarian pathology. Routine blood tests should be ordered:
- FBC and CRP – assess for the presence of any inflammatory response, which will be raised in biliary pathology such as cholecystitis, cholangitis, and pancreatitis
- U&Es – assess for any dehydration, secondary to reduced oral fluid intake (as certain foods can worsen the pain)
- LFTs – biliary colic and acute cholecystitis are likely to show a raised ALP (indicating ductal occlusion), yet the other parameters should remain within normal ranges.
- Amylase – to check for pancreatitis
Trans-abdominal ultrasound is one of the most sensitive modalities for visualising gallstone disease and is typically used first line to investigate suspected gallstone pathology (yet a sensitivity around 50%). Three specific areas are often visualised on US:
- The presence of gallstones or sludge (the start of gallstone formation)
- Gallbladder wall thickness (if thick walled, inflammation is likely)
- Bile duct dilatation (indicate a possible stone or stricture in the distal bile ducts)
If results from US scans are inconclusive, further imaging options are available. The gold standard investigation for gallstones is Magnetic Resonance Cholangiopancreatography (MRCP), largely replacing ERCP for diagnostic purposes (Fig. 3). MRCP can show potential defects in the biliary tree caused by gallstone disease, with a sensitivity approaching 100%. Any patient with symptoms suggestive of gallstones with inconclusive US (or CT scans) should undergo a MRCP.
Patients with biliary colic should be prescribed analgesia, typically NSAIDs and PRN opioids, along with an appropriate antiemetic. If there is no improvement in symptoms with analgesia, consider a potential cholecystitis picture.
The patient should be advised about lifestyle factors that may help control symptoms (and help with future surgery), such as a low fat diet, weight loss, increasing exercise, and provided with suitable analgesia at discharge
Following first presentation of biliary colic, there is a high chance of symptom recurrence or the development of complications of gallstones for example cholecystitis, or acute pancreatitis.
As a consequence, an elective cholecystectomy is warranted (or a surgical clinic review for consideration for a cholecystectomy) and should ideally be offered within 6 weeks of first presentation (Fig. 4). The laparoscopic route is preferred for cholecystectomy but is not always possible.
Patients with acute cholecystitis should be started on appropriate intravenous antibiotics (such as co-amoxiclav +/- metronidazole) and fluid resuscitation therapy. If the patient demonstrates evidence of sepsis, management should be adapted accordingly.
Ideally, an NG tube should be placed if the patient is vomiting and the patient made nil by mouth (NBM), as an ultrasound is more sensitive in the absence (or reduction) of bowel gas. Concurrent analgesia, typically simple analgesics with PRN opioids, and antiemetics should be prescribed
A laparoscopic cholecystectomy is indicated within 1 week, as per NICE guidelines, however this ideally should be done within 72hr of presentation*. A Cochrane review previously demonstrated that earlier cholecystectomies are safe and reduce overall hospital stay however, in many centres this is not currently practical.
For those not fit for surgery and not responding to antibiotics, a percutaneous cholecystostomy can be performed to drain the infection, with the patient advised regarding further lifestyle changes thereafter (although as the gallstones remain in-situ, the risk of recurring disease remains).
*A laparoscopic cholecystectomy after a couple of days of inflammation tends to be a more difficult procedure.
In a patient readmitted with RUQ pain post-cholecystectomy, it is important to exclude a retained CBD stone post-operatively. US abdomen scan may be useful, yet if this is unremarkable, then further investigation via MRCP imaging is warranted.
A gallbladder empyema is when the gallbladder is infected and an abscess forms within the gallbladder. Patients are typically septic, however presenting with a similar clinical picture to acute cholecystitis, and is associated with a significant morbidity and mortality.
The condition is diagnosed by either US scan or CT scan. Treatment is via laparoscopic cholecystectomy* (may require intra-operative drainage if tense gallbladder) or percutaneous cholecystostomy (if unsuitable for surgery).
*There is a higher rate of conversion to open cholecystectomy with emypema than with uncomplicated acute cholecystitis
Patients with chronic cholecystitis will typically have a history of recurrent or untreated cholecystitis, which has led to the chronic inflammation of the gallbladder wall. It may be asymptomatic or present with ongoing RUQ or epigastric pain with associated nausea and vomiting.
It can be diagnosed typically by CT scan (or often noted on histology post-cholecystectomy). Management in uncomplicated cases is via elective cholecystectomy. Its main complications are increased risk of gallbladder carcinoma and biliary-enteric fistula.
Bouveret’s Syndrome and Gallstone Ileus
Inflammation of the gallbladder (typically if recurrent or silent) can cause a fistula to form between the gallbladder wall and the duodenum, allowing gallstones to pass into the small bowel. As a consequence, bowel obstruction can occur:
- Bouveret’s Syndrome – stone impacts to cause duodenal obstruction
- Gallstone Ileus*– stone impacts to cause an obstruction at the terminal ileum (the narrowest part of the adult bowel)
Other complications include obstructive jaundice, ascending cholangitis, and acute pancreatitis.
*The term ileus is misleading, as it is actually a bowel obstruction
- Gallstones are a very common condition, either symptomatic or asymptomatic
- Risk factors include high-fat diet, female gender, malabsorption, and oral contraceptive use
- Most cases can be diagnosed by US abdomen scan, yet MRCP is the gold-standard investigation
- Definitive treatment for simple gallstone disease is via laparoscopic cholecystectomy