Cholelithiasis management

Cholelithiasis management

Cholelithiasis involves the presence of gallstones which are concretions that form in the biliary tract, usually in the gallbladder. Choledocholithiasis refers to the presence of one or more gallstones in the common bile duct (CBD). Treatment of gallstones depends on the stage of disease.

Clinical presentation

• Asymptomatic in majority of patients

• Biliary pain (episodic RUQ or epigastric pain), pain radiating to scapula

• Pain precipitated by fatty foods

• Nausea

• Physical exam: afebrile, and/or RUQ tenderness or epigastric pain

• Nonspecific symptoms (e.g., indigestion, dyspepsia, belching, or bloating)

Investigations

• Full blood count

• Liver function panel

• Pancreatic enzymes (amylase, lipase)

• Abdominal radiography (upright and supine) – to exclude other causes of abdominal pain

• Ultrasonography

• CT scan – superior for demonstrating stones in the distal CBD

• MRI with MRCP

• Scintigraphy (HIDA) scans

• Endoscopic retrograde cholangiopancreatography (ERCP)

• Percutaneous transhepatic cholangiography (PTC)

Complications

• Cholecystitis

• Choledocholithiasis leading to cholangitis or gallstone pancreatitis

• Mirizzi syndrome

• Cholecystenteric fistula (stone erodes through gallbladder into bowel)

• Gallstone ileus: small bowel obstruction (usually at terminal ileum) due to stone in intestine that passed through fistula

• Gallbladder carcinoma

Non-pharmacological treatment

• Asymptomatic gallstones – expectant management

• Symptomatic gallstones – definitive surgical intervention (cholecystectomy)

Pharmacological treatment

• Paracetamol (PO) 1 g 8 hourly for 5 days

  
  

  OR

• Ibuprofen (PO) 400 mg 4–6 hourly for 3–5 days

  
  

  OR

• Tramadol (PO) 50 mg 12 hourly for 3–5 days

AND

• Ursodeoxycholic acid 8–10 mg/kg/day divided once to three times daily up to 6 months

Note

Cholecystectomy (open or laparoscopic) for asymptomatic gallstones may be indicated in the following:

• Those with large (>2 cm) gallstones

• Nonfunctional or calcified (porcelain) gallbladder on imaging studies and at high risk of gallbladder carcinoma

• Those with spinal cord injuries or sensory neuropathies affecting the abdomen

• Sickle cell anemia patients (difficult to distinguish between painful crisis and cholecystitis)

Additional procedures:

• Cholecystectomy

• Endoscopic sphincterotomy

• Extracorporeal shockwave lithotripsy