Management of gallstones

What it is

Cholelithiasis is gallstones in the gallbladder; choledocholithiasis is gallstones in the common bile duct (CBD). The types of stone are cholesterol, pigmented, which goes with chronic hemolysis, and mixed.

Causes and risk

Gallstones carry the F risk factor features: female, fat, forty, fertile. They are also the first cause of acute pancreatitis worldwide, with alcohol second. Some patients are moved to surgery even when the stones are quiet, as exceptions to expectant management: a large stone, greater than 3 cm in one text; hemolytic disease, put as SCD and as hemolytic anemia; a porcelain gallbladder, also put as calcification of the gallbladder; an immunocompromised patient; small gallstones with gallbladder dysmotility; a morbidly obese patient undergoing bariatric surgery; a patient planning to have a transplant; and Native Americans.

How it presents

Gallstones are often asymptomatic and found incidentally on imaging. When they become symptomatic they usually cause pain in the right upper quadrant or the epigastrium. Most patients with symptomatic gallstones present with chronic cholecystitis, which causes recurrent attacks of pain: the pain is constant, increases in severity at the beginning, and lasts from 1 to 5 hours. It often starts during the night after a fatty meal and may come with nausea and vomiting. That mild recurrent pain sits on a list with biliary colic, gastritis, peptic ulcer and GERD.