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Gallstones Follow the Link from the Online Version of This Article to Obtain Certi Ed Continuing Medical Education Credits Kurinchi S Gurusamy, Brian R Davidson

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Gallstones Follow the Link from the Online Version of This Article to Obtain Certi Ed Continuing Medical Education Credits Kurinchi S Gurusamy, Brian R Davidson CLINICAL REVIEW Gallstones Follow the link from the online version of this article to obtain certi ed continuing medical education credits Kurinchi S Gurusamy, Brian R Davidson Department of Surgery, 9th floor Gallstones affect approximately 5‑25% of adults in the SUMMARY POINTS Royal Free Hospital, Royal Free Western world. It is therefore important to understand Campus, UCL Medical School, Gallstones are common in adults the consequences of a diagnosis of gallstones, the asso‑ London, UK Currently, treatment is indicated only for symptomatic ciated complications, and treatment to allow patients to Correspondence to: K Gurusamy gallstones [email protected] be appropriately advised. The purpose of this review is Pain is the most common symptom related to gallstones Cite this as: BMJ 2014;348:g2669 to update clinicians on the diagnosis and management doi: 10.1136/bmj.g2669 Occasionally gallstones present with life threatening of gallstones. complications Surgery is the only definitive treatment and is bmj.com What are gallstones? Previous articles in this recommended for people with symptomatic gallstones Gallstones are crystalline deposits in the gallbladder (fig‑ who are fit to undergo surgery series 1 ure). The prevalence of gallstones varies between 5% Laparoscopic cholecystectomy is currently the preferred Ж First seizures in adults and 25%, with a higher prevalence in Western countries, method of surgery and is generally both effective and (BMJ 2014;348:g2470) women, and older age group.2 Traditionally, gallstones safe; however, there is a 0.3% risk of serious injury Ж Obsessive-compulsive were classified as cholesterol stones, pigment stones, or to the bile duct, which may have serious long term disorder mixed stones (a combination of cholesterol and pigment consequences (BMJ 2014;348:g2183) stones) based on their composition,3 which can only be Ж Modern management determined reliably after their removal.4 Recently, addi‑ levels, decreased gallbladder motility, and the phosphati‑ of splenic trauma tional types of gallstones have been identified based on dylcholine molecule, which prevents the crystallisation (BMJ 2014;348:g1864) their microscopic structure and composition.1 However, of cholesterol.5 The main risk factors for cholesterol stone Ж Fungal nail infection: most stones fall under the umbrella of cholesterol (37‑ formation include female sex, pregnancy, high dose oes‑ 86%), pigment (2‑27%), calcium (1‑17%), or mixed trogen treatment, increasing age, ethnicity (higher preva‑ diagnosis and 1 4 management (4‑16%). The types of gallstone vary by their cause, lence in Native American Indians and lower prevalence in (BMJ 2014;348:g1800) the measures attempted to prevent their formation, their black Americans, Africans, and people from China, Japan, appearance on radiographs, and their response to disso‑ India, and Thailand), genetic traits, obesity, high serum Ж Endometriosis lution therapy. The current recommendations for diagno‑ triglyceride levels, low levels of high density cholesterol, (BMJ 2014;348:g1752) sis and management are, however, the same for all types rapid weight loss, high calorific diet, refined carbohydrate of gallstone. diet, lack of physical activity, cirrhosis, Crohn’s disease, and gallbladder stasis (for example, as a result of previ‑ Who gets gallstones? ous gastrectomy or vagotomy).6‑8 Haemolysis and chronic Cholesterol stones are formed because of the alteration bacterial or parasitic infections are considered the main in the balance between pronucleating factors and antinu‑ risk factors for pigment stones5 and are preventable cleating factors in the bile. Factors that lead to gallstone causes of gallstones. formation include excessive bile cholesterol, low bile salt Can gallstone formation be prevented? Although some of the causes of gallstones, such as obe‑ sity, rapid weight loss, a high calorific diet, a refined carbohydrate diet, and lack of physical activity are preventable by lifestyle changes, there is currently no Liver evidence that lifestyle modifications can reduce the incidence of gallstones. Haemolysis and infections can be prevented by early recognition of sickle cell disease, Gallbladder taking appropriate measures for prevention of sickling Stomach Gallstones crises, and using prophylactic antibiotics in those who Common duct stones have undergone splenectomy or had splenic infarc‑ tion. Another way of preventing gallstone formation is Common bile duct to remove the gallbladder in people undergoing anti‑ Pancreas obesity operations (as rapid weight loss is one of the Common Duodenum duct stones SOURCES AND SELECTION CRITERIA (rst part of small intestine) Ampulla of Vater We searched Medline, Embase, the Cochrane Database of Systematic Reviews, and Clinical Evidence online using the search terms “gallstones” or “cholelithiasis”, focusing mainly on systematic reviews, meta-analyses, and high Obstruction to the common bile duct by common duct stones may cause jaundice or quality randomised controlled trials published within the cholangitis. Obstruction to the pancreatic duct or ampulla of Vater by common duct stones past five years, wherever appropriate and possible. may cause pancreatitis BMJ | 26 APRIL 2014 | VOLUME 348 27 CLINICAL REVIEW risk factors for gallstone formation) and other major by the European Association for Endoscopic Surgery Complications of gallstones abdominal op‑erations to avoid further surgery as a result c oncluded that common bile duct stones should be sus‑ of the development of symptomatic gallstones. There is pected by the presence of clinical features suggestive of • Acute cholecystitis currently no evidence to suggest that prophylactic chol‑ obstructive jaundice, such as yellowish discoloration of • Choledocholithiasis ecystectomy is indicated in any patient group without skin and dark urine supported by an increased serum • Acute cholangitis gallstones9 or that any of the above suggested measures bilirubin or alkaline phosphatase level and confirmed • Acute pancreatitis of preventing gallstones are effective. with magnetic resonance cholangiopancreatography • Mucocele of gallbladder or endoscopic ultrasonography.26 27 Fever and rigors in • Empyema of gallbladder How do gallstones present? the presence of jaundice should raise the suspicion of • Gangrenous gallbladder Each year approximately 2‑4% of people with gallstones cholangitis. • Biliary peritonitis develop symptoms, with biliary colic being the most com‑ If patients present with symptoms suggestive of gall‑ • Porcelain gallbladder mon symptom (steady right upper quadrant abdominal stones, are systemically well, and do not have features • Gallbladder cancer pain lasting more than half an hour)10‑14 in the absence suggestive of acute cholecystitis, acute pancreatitis, of fever. Presence of fever usually indicates acute chol‑ obstructive jaundice, or cholangitis, it is reasonable to ecystitis or cholangitis. Other common symptoms related investigate them by an elective ultrasonography, followed to gallstones include epigastric pain and intolerance to by elective referral to a general surgeon if gallstones are fried or fatty foods (symptoms such as nausea, bloating, present. If gallstone complications are suspected, urgent flatulence, frothy and foul smelling stools).14 The box referral to the surgeon is warranted because early confir‑ lists the complications resulting from gallstones, and mation of diagnosis and treatment of complications are includes acute cholecystitis (0.3‑0.4% annually),11‑13 15 associated with better outcomes (see section on timing acute pancreatitis (0.04‑1.5% annually),15 obstructive of surgery). Features that suggest the presence of com‑ jaundice (0.1‑0.4% annually),12 13 15 and other rarer plications include fever, rigors, hypotension, epigastric complications such as acute cholangitis and intestinal pain radiating to the back, dark urine, jaundice, Murphy’s obstruction (gallstone ileus). Of these, acute pancrea‑ sign, diffuse abdominal tenderness, or a positive result for titis and cholangitis are life threatening complications, urine bile pigments on urinalysis. Depending on the clini‑ with 3% to 20% mortality after a first attack of acute cal presentation, further blood tests, such as white cell pancreatitis16 and 24% mortality after acute cholangi‑ count, levels of serum C reactive protein, serum amylase, tis.17 Uncomplicated biliary colic often precedes other serum bilirubin, and serum alkaline phosphatase; urine gallstone related complications.11 The rates of gallstone tests to check levels of urine amylase and urine lipase; related complications are higher in people with a history and radiological investigations such as ultrasonogra‑ of uncomplicated biliary colic.18 Although studies have phy, computed tomography, magnetic resonance imag‑ shown an association between gallstones and cancer of ing, magnetic resonance cholangiopancreatography, the biliary tract,19 20 no causative link has been estab‑ and endoscopic ultrasonography may be performed to lished and the observed association could be due to the confirm or rule out the presence of gallstones and com‑ presence of common factors causing gallstones and gall‑ plications. bladder cancer.21 How is gallstone disease treated? How should suspected gallstones be investigated? Asymptomatic gallstones Ultrasonography is currently the first line method for The distinction between symptomatic and asymptomatic the diagnosis of gallstones and has a high diagnostic gallstones can be difficult as symptoms can
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