Identifying and treating gallstones

Patients with upper abdominal pain could have gall bladder disease, says Dr Alison Glenesk.

Gallstones will occur in 10-15 per cent of the UK populationMost gallstones are composed of cholesterol, bile salts and phospholipids in varying proportions. Whether as a collection of sludge in the gall bladder or a 'pearl' a few centimetres in diameter, gallstones will occur in 10-15 per cent of the adult UK population, but not all will be symptomatic.

Traditionally, patients at risk of gallstones can be identified using the four 'F's: fair (female), fat, fertile and forty.

A family history increases gallstone risk, as does diabetes, rapid weight loss, parenteral nutrition, contraceptive Pill use, and loss of bile salts through terminal ileitis or ileal resection.

How do gallstones present?
Patients with gallstones might present with a variety of complaints, depending on the site of the stone (see box). The most common presentations are:

  • Biliary colic - this accounts for 56 per cent of patients presenting with gallstones. It is caused by a stone moving into the cystic duct, resulting in epigastric or right upper quadrant pain lasting for up to several hours. There might be nausea and vomiting but no fever.
  • Cholecystitis - this is similar to biliary colic, but with fever and right upper quadrant tenderness. It is usually longer-lasting and affects 36 per cent of patients presenting with gallstones.
  • Obstructive jaundice - this is occasionally the presenting complaint, and can cause a great deal of anxiety. It is usually painful and caused by a stone migrating into the bile duct. Pancreatitis can also be the first presentation.

Diagnosis
Patients presenting classically, with fever and right upper quadrant pain after eating a fatty meal, are easy to diagnose.

However, diagnosis is not always so easy because abdominal pain might be poorly localised, and nausea and vomiting are common and non-specific.

Similarly, the time-honoured symptom of fat-intolerance is not always helpful. Murphy's sign (pain on palpation under the right costal margin on inspiration) can be positive, but is by no means universal. It is important to consider gall bladder disease in anyone presenting with upper abdominal pain.

Differential diagnoses include irritable bowel syndrome, peptic ulcer disease, pancreatitis and non-ulcer dyspepsia.

Complications

Complications include:

  • Jaundice.
  • Pancreatitis - the migration of small stones through the Ampulla of Vater can cause temporary obstruction. This is a clinical emergency, and classically presents with epigastric pain radiating to the back, often with profuse vomiting.
  • Ascending cholangitis - stones found in the common bile duct can cause stasis followed by infection. This can be diagnosed using Charcot's triad of jaundice, fever and right upper quadrant pain.
  • Empyema of the gall bladder - this causes symptoms of severe sepsis and is an emergency.
  • Gallstone ileus - this rare complication occurs when a sizeable stone creates a fistula directly into the duodenum causing obstruction in the small bowel.

Treatment and investigation
Some patients require admission to hospital.

Most will settle with analgesia such as pethidine or diclofenac, and a broad-spectrum antibiotic if infection is suspected.

Routine blood tests might also show deranged liver function tests. An ultrasound scan will reliably detect gallstones in the gall bladder. It will only show about half of stones in the common bile duct but dilation of the duct may indicate this complication.

Routine surgical referral will take place after detection of gallstones, whereas gallstones presenting with jaundice require urgent action.

Cholecystectomy
Cholecystectomy is the treatment of choice for most patients. Around 90 per cent of cholecystectomies are done laparoscopically, shortening hospital stay and recovery time compared with open surgical approaches.

The operation usually involves a two-day admission, but several studies have found that day-case surgery complication rates and patient acceptability are similar to those with traditional laparoscopic operations, with yearly cost savings of £8 million for the NHS, so cholecystectomy stays may become shorter.

Another controversial issue is the timing of cholecystectomy. A Cochrane review has advocated that patients admitted with acute cholecystitis would benefit from immediate cholecystectomy. However, this is not usual practice.

A recent UK study found that around a quarter of patients on the cholecystectomy waiting list were re-admitted as an emergency due to gallstone related symptoms.

Taking this into account together with the time spent by GPs treating the patients at home, it surely makes sense to treat these patients early.

Percutaneous drainage
Percutaneous drainage is used to drain an infected gall bladder through the skin in high-risk patients. It is less invasive than cholecystectomy, and the outcome is usually satisfactory.

ERCP
Endoscopic retrograde cholangiopancreatography (ERCP) is a laparoscopic technique used to remove stones from the common bile duct via an endoscope inserted orally.

It can be followed by laparoscopic cholecystectomy, but this is not always necessary since 60-80 per cent of patients will become asymptomatic following ERCP alone.

Asymptomatic patients
There is some debate over whether or not to treat gallstones in asymptomatic patients.

Patients develop symptoms at the rate of 1-4 per cent per year, so observation is the best approach when operative complications such as infection and damage to the bowel are considered. Some patients experience ongoing long-term right upper quadrant pain and dyspeptic symptoms following surgery.

The future
A technique known as 'natural orifice transluminal endoscopic surgery' is being developed which will allow intraperitoneal surgery to be performed via the mouth or anus.

Dr Glenesk is a GP trainer in Aberdeen.

References

  • Sanders G, Kingsnorth A. Clinical Review: Gallstones. BMJ 2007; 335: 295-9.
  • Gurusamy K, Samraj K. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Cochrane Database of Systematic Reviews 2006, Issue 4.
  • Somasekar K, Shankar P, Foster M. Costs of waiting for gall bladder surgery. Postgraduate Medical Journal 2002; 78: 668-9.
Conditions caused by gallstones
Site of stone Possible presentation
Gall bladder Cholecystitis
Gall bladder/cystic duct Biliary colic
Common bile duct Obstructive jaundice, cholangitis
Ampulla Pancreatitis
Small bowel (via fistula)Obstruction

 

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