Signs and Symptoms

Potential causes:

• Pro-nucleating factors, such as:
  • biliary glycoprotein
  • biliary mucin
• Impaired gallbladder mobility
• Elevated levels of hydrophobic biliary deoxycholate (e.g. due to presence of Gram positive anaerobic bacteria with 7α-dehydroxylation activity)
• Chronic enteritis:
  • e.g. due to infection, or Crohn's disease
  • may predispose to gallstone formation by impairing bile acid entero-hepatic circulation and metabolism

Asymptomatic gallstones:

• Are usually discovered incidentally by imaging or during abdominal surgery
• Account for the majority of gallstones (more than 80%)
• Become problematic in about:
  • 1-4% of patients within a year
  • 10% of patients within 10 years
  • 20% of patients within 20 years
• Most patients will experience symptoms of biliary colic before developing complications
• The longer the gallstones remain quiescent, the less likely the patient is to develop complications

Symptomatic gallstones:

• Are sometimes associated with systemic symptoms (eg fever) or raised markers of inflammation (e.g. leucocytes, C-reactive protein)
• Biliary colic is caused by the gallbladder contracting against an obstructed cystic duct
• Patients present with pain that is:
  • severe − can last continuously for as long as 5 hours, and may wake patient at night
  • intermittent − typically separated by weeks/months
  • episodic − after an episode of biliary pain, 2/3 of patients re-present within 2 years
  • located in the right upper quadrant or epigastric region (although may radiate to the right scapula, shoulder or, occasionally, retrosternally)
  • gradually resolving:
    • either spontaneously or with analgesics
    • resolves when the gallbladder stops contracting, or the cystic duct becomes patent again
    • pain that doesn't resolve could be indicative of a complication
  • typically brought on by fatty foods
  • sometimes associated with diaphoresis, nausea, and/or vomiting
  • sometimes associated with belching, bloating, flatulence, and/or dyspepsia (although these symptoms cannot be directly attributed to gallstones)
• Being symptom-free for 5 years (or more) reduces the risk of developing further episodes of biliary colic (or associated complications) to that of an asymptomatic gallstone carrier

History and Examination

An initial clinical assessment should identify:

• Patients with known gallstone disease who:
  • are developing/have developed serious complications requiring urgent surgical referral and intervention
  • present with increasingly frequent and painful episodes of acute biliary colic, for whom conservative therapy has failed and definitive surgical intervention is the next step
• Patients with asymptomatic gallstones (picked up incidentally) who present with atypical symptoms and signs:
  • symptoms should not automatically be attributed to cholelithiasis
  • may require further investigation to exclude other causes of epigastric/right upper quadrant pain, including:
    • gastritis/peptic ulcer disease
    • oesophageal spasm
    • myocardial ischaemia/infarction
    • intestinal obstruction/colitis/diverticulitis
    • liver/subphrenic abscess
    • hepatitis
    • pancreatitis
    • irritable bowel syndrome
• Patients who have developed atypical pain and/or non-specific symptoms (eg chronic indigestion, vague abdominal pain, bloating, belching) − may merit further investigation (warn patient that cholecystectomy may not improve their symptoms)

Differential Diagnoses

Other causes of epigastric/RUQ pain include:

• Gastritis/peptic ulcer disease
• Oesophageal spasm
• Myocardial ischaemia/infarction
• Intestinal obstruction/colitis/diverticulitis
• Liver/subphrenic abscess
• Hepatitis
• Pancreatitis
• Irritable bowel syndrome

Symptomatic

If there is suspicion of any of the following, urgent referral to A&E or the on-call surgical team for further investigation should be considered:

• Haemodynamic compromise (ie hypotensive, tachycardic)
• Acute abdomen:
  • guarding with/without rebound tenderness − indicates localised/generalised peritonitis
  • acute intestinal obstruction
  • gastrointestinal (GI) haemorrhage
• Acute cholecystitis:
  • persistent right upper quadrant (RUQ)/epigastric pain with marked tenderness − indicates localised peritonitis
  • a positive Murphy's sign:
    • indicative of inflammation associated with acute cholecystitis
    • elicited by placing a hand at the costal margin in the right upper quadrant and asking the patient to breathe deeply
    • an inflamed gallbladder is indicated by patient experiencing pain and catching their breath as the gallbladder descends
    • low-grade pyrexia (high-grade pyrexia may indicate cholangitis)
  • patients may present more profoundly unwell if they develop sequelae of untreated cholecystitis, including gallbladder abscess, empyema and perforation
• Jaundice:
  • gallstones associated with painful jaundice indicates obstruction of the common bile duct by a gallstone migrating from the gallbladder
  • painless jaundice is rarely attributable to gallstone pathology
  • patients may complain of pale stool and/or dark urine
• Acute cholangitis:
  • Charcot's triad of jaundice, RUQ pain, and fever (typically with rigors) is diagnostic
  • indicates super-added infection of the obstructed biliary system
• Acute pancreatitis:
  • profuse vomiting
  • central epigastric pain radiating through to the back
  • difficult diagnosis to make in primary care, but should be considered in all unwell patients with a history of gallstones

Investigation requirements for Gallstone clinic are as follows:

• Ultrasound
• Any suggestion of Jaundice
• Liver function test

Consider LFT, Bloods

Blood work :

• Blood tests are not usually indicated in the diagnosis of gallstones
• The majority of patients with episodic biliary colic would demonstrate normal blood results
• Elevated inflammatory markers would make the diagnosis of uncomplicated biliary colic unlikely, and should prompt further investigation
• However, mildly elevated liver function tests can be associated with gallstones if testing takes place during an episode of acute pain

Imaging:

• Where available, abdominal ultrasound is a suitable non-invasive first-line choice
  • Sensitivity varies widely and is operator dependent
• Ultrasound findings of a thickened gallbladder wall and pericholecystic fluid would suggest the presence of acute cholecystitis
• Radionuclide scanning is not a useful test for the diagnosis of gallstone disease, but may be used to detect acute cholecystitis

Asymptomatic

Prophylactic cholecystectomy in asymptomatic gallstone patients is not routinely recommended as the risks of surgical intervention outweigh the perceived benefits.

However, prophylactic removal of the gallbladder may be considered on a case-by-case basis in patients with asymptomatic gallstones who:

• Have an increased risk of gallbladder cancer, eg due to:
  • a calcified (porcelain) gallbladder
  • a family history of gallbladder cancer
• Suffer from sickle cell disease

Asymptomatic gallstone carriers may be advised the following in order to prevent conversion to a symptomatic state:

• Increased physical activity
• Decreased total calorie intake
• Moderate coffee and nut consumption

Symptomatic (initial management)

Acute episode management:

• Management of an acute episode of uncomplicated biliary pain or colic should be directed at controlling symptoms such as pain and nausea
• Most episodes may be managed at home
• Opioid-analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) are both effective for pain management
• Antiemetics may be of use
• Patients may be advised to remain fasting during the episode of biliary colic in order to reduce the release of cholecystokinin and reduce gallbladder contraction
• Intravenous (IV) hydration may be necessary in prolonged attacks
• Episodes lasting more than 24 hours or associated with fever should be referred to hospital (suggests acute cholecystitis)

Encourage lifestyle changes to possibly decrease risk of further episodes of biliary colic:

• Increased physical activity
• Decreased total calorie intake
• Moderate coffee and nut consumption

If surgery is not an option consider medical management of the following:

• Continue analgesics with/without antiemetics for acute pain management
• Lifestyle changes, such as :
  • weight loss
  • increased exercise
  • decreased calorie intake
• Oral bile salt therapy with ursodeoxycholic acid:
  • may be beneficial in a small cohort of patients with small (less than 5mm) non-calcified, cholesterol stones in a functioning gallbladder (who present with mild colic)
  • however, this is not a definitive treatment and recurrence is common
  • these patients are at risk for developing gallstone complications and therefore merit a low threshold for referral to surgeons for emergency assessment

Formulary Chapter 1 Gastrointestinal

Referral Criteria

Consider referral to Gallstone Clinic surgeons for elective laparoscopic cholecystectomy if :

• Patient expresses willingness to undergo surgery
• Patient is medically fit enough to undergo surgery

NB: It may still be worth referring patients who are borderline, as a thorough preoperative assessment and anaesthetic review should identify those who are fit.

Referral Instructions

• Specialty: GI & Liver (medicine and surgery)
• Clinic type: Gallstones
• Service: DRSS-Northern-GI & Liver (Medicine & Surgery) -Devon CCG-15N

Referral Forms

DRSS Referral forms

Patient Information

MyHealth Devon - Gallstones

Gallstones & Cholecystectomy guide for patients

Pathway Group

This pathway was signed off on behalf of NHS Devon.

Publication date: June 2015

Reviewed: April 2024