A Synopsis of AFP's "Surgical and Nonsurgical Management of Gallstones"

A Synopsis of:
Surgical and Nonsurgical Management of Gallstones
SHERLY ABRAHAM, MD; HAIDY G. RIVERO, MD; IRINA V. ERLIKH, MD; LARRY F. GRIFFITH, MD; and VASANTHA K. KONDAMUDI, MD, The Brooklyn Hospital Center, Brooklyn, New York
Am Fam Physician. 2014 May 15;89(10):795-802
http://www.aafp.org/afp/2014/0515/p795.pdf

     Gallstones are made of cholesterol or calcium. Risk factors for gallstone formation include diabetes, obesity, metabolic syndrome, dyslipidemia, hyperinsulinemia, and high-calorie diets. Typical presentation includes abrupt, steady, right upper quadrant pain. Pain peaks within one hour and resolves after the stone passes (1-5 hours). Complications include acute cholecystitis (fever, leukocytosis, RUQ pain), cholangitis (charcot's triad is fever, jaundice and abdominal pain), and gallstone pancreatitis (sphincter of Oddi obstruction).  Choledocholithiasis is an obstruction of the common bile duct. Risk factors include symptoms of cholangitis, a bilirubin level above 4 mg/dl, or a common bile duct wider than 6mm. 
    Ultrasound is the first line choice of imaging because of cost and low invasiveness. CT is superior to ultrasound, but it is more expensive and has radiation exposure. MRCP is a second line choice as well.
     HIDA scan is used to visualize the biliary tree and assess liver and gallbladder function.  The patient is given iminodiacetic acid which can be detected with a gamma camera as it travel through the liver and gallbladder in the bile. ERCP is diagnostic and therapeutic because is can be used to retrieve the stone, add a stent, or collect a biopsy.  
     Treatment depends on several factors. If the gallstone is asymptomatic, the patient can be followed clinically or sent for laparoscopic cholecystectomy. Symptomatic patients should be treated with NSAIDs or narcotics (meperidine or ketorolac). Scopolamine is not as effective. Complications (choledocholithiasis, cholecystitis, pancreatitis) may be referred to surgery as well.  If the patient is not a candidate for surgery, treatments such as oral dissolution therapy or extracorporeal shock wave therapy can be considered. Oral dissolution therapy is best with gallstones 5 mm or smaller, although the therapy can take up to two years. Patients with calcified gallbladders, hemolytic anemia, stones larger than 3 cm, morbid obesity undergoing bariatric surgery, native american heritage, or bladder dysmotility are exceptions to expectant management.
     Antibiotic prophylaxis is generally not required for laparoscopic cholecystectomy. High risk patients may benefit from a single dose of cefazolin. 
     Pregnant patients should not be given NSAIDs. Meperidine is appropriate. Ursodeoxycholic acid is another option. Surgery can be considered for patients in recurrent or intractable pain.