318 Cholelithiasis
• Surgical intervention is generally the
BASIC INFORMATION
DEFINITION
Cholelithiasis is the presence of stones in the
gallbladder
SYNONYMS
Gallstones
ICD-9CM CODES
574.2 Calculus of the gallbladder without
mention of cholecystitis
574.0 Calculus of the gallbladder with acute
cholecystitis
ICD-10CM CODES
K80.2 Calculus of gallbladder without
cholecystitis
K80.5 Calculus of bile duct without
cholangitis or cholecystitis
EPIDEMIOLOGY &
DEMOGRAPHICS
• Gallstone disease can be found in 12% of the
U.S. population. Of these, 2% to 3% (500,000
to 600,000) are treated with cholecystecto-
mies each year.
• Annual medical expenditures for gallbladder
surgeries in the U.S. exceed $5 billion.
• Incidence of gallbladder disease increases
with age. Highest incidence is in the fifth
and sixth decades. Predisposing factors for
gallstones are female sex, pregnancy, age
>40 yr, family history of gallstones, obesity,
ileal disease, oral contraceptives, diabe-
tes mellitus, rapid weight loss, estrogen
replacement therapy. Risk factors for the
development of cholelithiasis are described
in Table EC1-13.
• Patients with gallstones have a 20% chance
of developing biliary colic or its complications
at the end of a 20-yr period.
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
• Physical examination is entirely normal
unless patient is having biliary colic; 80% of
gallstones are asymptomatic.
• Typical symptoms of obstruction of the cystic
duct include intermittent, severe, cramping
pain affecting the right upper quadrant.
• Pain occurs mostly at night and may radiate
to the back or right shoulder. It can last from
a few minutes to several hours.
ETIOLOGY
• 75% of gallstones contain cholesterol and
are usually associated with obesity, female
sex, and diabetes mellitus; mixed stones are
most common (80%); pure cholesterol stones
account for only 10% of stones.
• 25% of gallstones are pigment stones (bili-
rubin, calcium, and variable organic mate-
rial) associated with hemolysis and cirrhosis.
These tend to be ­ black-pigmented stones
that are refractory to medical therapy.
• 50% of mixed-type stones are radiopaque.
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• Peptic ulcer disease
• Gastroesophageal reflux disease
• Irritable bowel disease
• Pancreatitis
• Neoplasms
• Nonnuclear dyspepsia
• Inferior wall myocardial infarction
• Hepatic abscess
LABORATORY TESTS
Generally normal unless patient has biliary
obstruction (elevated alkaline phosphatase, bili-
rubin).
IMAGING STUDIES
• Ultrasound of the gallbladder (Fig. EC1-62)
will detect small stones and biliary sludge
(sensitivity, 95%; specificity, 90%); the pres-
ence of dilated gallbladder with thickened
wall is suggestive of acute cholecystitis.
• Nuclear imaging (HIDA scan) can confirm
acute cholecystitis (>90% accuracy) if gall-
bladder does not visualize within 4 hr of
injection and the radioisotope is excreted in
the common bile duct.
• Common bile duct stones can be detected
noninvasively by magnetic resonance chol-
angiopancreatography or invasively by endo-
scopic retrograde cholangiopancreatography
(ERCP) and intraoperative cholangiography.
TREATMENT
NONPHARMACOLOGIC THERAPY
Lifestyle changes (avoidance of diets high in
polyunsaturated fats, weight loss in obese
patients; however, avoid rapid weight loss)
ACUTE GENERAL Rx
• The management of gallstones is affected by
the clinical presentation.
• Asymptomatic patients do not require thera-
peutic intervention. Proposed criteria for pro-
phylactic cholecystectomy are described in
Table C1-14.
TABLE C1-14  Proposed Criteria
for Prophylactic Cholecystectomy
Life expectancy >20 years
Calculi >2 cm in diameter
Calculi >3 mm and patent cystic duct
Radiopaque calculi
Gallbladder polyps >15 mm
Nonfunctioning or calcified gallbladder
(“porcelain” gallbladder)
Women <60 years
Patients in areas with high prevalence of gall-
bladder cancer
From Cameron JL, Cameron AM: Current surgical therapy, ed
10, Philadelphia, 2011, Saunders.
ideal approach for symptomatic patients.
Laparoscopic cholecystectomy is preferred
over open cholecystectomy because of the
shorter recovery period and lower mortal-
ity rate. Between 5% and 26% of patients
undergoing elective laparoscopic cholecys-
tectomy will require conversion to an open
procedure. Most common reason is the
inability to clearly identify the biliary anatomy.
• Laparoscopic cholecystectomy after endo-
scopic sphincterectomy is recommended for
patients with common bile duct stones and
residual gallbladder stones. Where possible,
single-stage laparoscopic treatments with
removal of duct stones and cholecystectomy
during the same procedure are preferable.
Percutaneous cholecystectomy is an alter-
native for patients who are critically ill with
gallbladder empyema and sepsis.
• Patients who are not appropriate candidates
for surgery because of coexisting illness or
patients who refuse surgery can be treated
with oral bile salts: ursodiol or chenodiol.
Candidates for oral bile salts are patients
with cholesterol stones (radiolucent, noncal-
cified stones), with a diameter of ≤15 mm
and having three or fewer stones. Candidates
for medical therapy must have a functioning
gallbladder and must have absence of calci-
fications on CT scans.
• Extracorporeal shock wave lithotripsy (ESWL)
is another form of medical therapy. It can be
used in patients with stone diameter of ≤3
cm and having three or fewer stones.
DISPOSITION
• Recurrence rate after bile acid treatment is
approximately 50% in 5 yr. Periodic ultra-
sound is necessary to assess the effective-
ness of treatment.
• After ESWL, stones recur in approximately
20% of patients after 4 yr.
• Patients with at least one gallstone <5 mm
in diameter have a greater than fourfold
increased risk of presenting with acute biliary
pancreatitis. A policy of watchful waiting in
such cases is generally warranted.
• A potential serious complication of gallstones
is acute cholangitis. ERCP and endoscopic
sphincterectomy followed by interval laparo-
scopic cholecystectomy are effective in acute
cholangitis.
SUGGESTED READINGS
Available at www.expertconsult.com
RELATED CONTENT
Gallstones (Patient Information)
Cholecystitis (Related Key Topic)
AUTHOR: FRED F. FERRI, M.D.
Cholelithiasis 318.e1

SUGGESTED READINGS
Abraham S, et al.: Surgical and nonsurgical management of gallstones, Am Fam
Physician 89(10):795–802, 2014.
Bellows CF, et al.: Management of gallstones, Am Fam Physician 72(637), 2005.
Moon JH, et al.: The detection of bile duct stones in suspected biliary pancreatitis:
comparison of MRCP, ERCP, and intraductal US, Am J Gastroenterol 100(1051),
2005.

TABLE EC1-13  Symptoms of Gallstone Disease and Its Complications

Disease
Biliary colic
Acute cholecystitis
Emphysematous cholecystitis
Chronic cholecystitis
Acalculous cholecystitis
Gallbladder perforation
Pathophysiology
Transient gallstone impaction at the cystic duct or
ampulla of Vater
Inflammation of the gallbladder caused by obstruction
of the cystic duct May occur in the presence or
absence of bacterial superinfection
Infection with gas-producing bacteria such as
Escherichia coli, Clostridium perfringens, and
anaerobic streptococci
Persistent inflammation and fibrosis of the gallbladder
with poor motor and absorptive function
Probably related to biliary stasis in the setting of
­critical illness and altered gastrointestinal motility
Stones erode through an inflamed and necrotic
­gallbladder wall Stones may travel into the
­peritoneal cavity or cause adhesions between
nearby structures Bile peritonitis may develop
Symptoms
Intermittent RUQ pain associated with nausea or vomiting. Pain in the
epigastrium or radiating to the right scapular tip. Episodes last
30 min to several hours with days or months between episodes.
Patients appear ill and cannot take deep breaths. They have constant
pain that lasts 30-60 min and worsens with movement. Persistent
common bile duct impaction usually promotes vomiting. Physical
examination demonstrates RUQ tenderness with voluntary guarding
and a positive Murphy sign (arrest of inspiration during deep
palpation over the gallbladder).
Symptoms are similar to those with acute cholecystitis.Gas may be seen
on abdominal plain films or CT. Male diabetics are most commonly
affected.
Patients are usually asymptomatic but may report multiple previous
attacks of colic. Porcelain gallbladder develops from chronic inflam-
mation and may progress to carcinoma.
Seen in patients with traumatic injuries, burns, and critical illness, as
well as in those receiving total parenteral nutrition. The mortality for
this disorder is twice as high as that for acute calculous cholecystitis.
More than half of patients with gallbladder perforation have fever and a
palpable RUQ mass. Mortality in these patients is 30%.

CT, Computed tomography; RUQ, right upper quadrant.

From Adams JG et al: Emergency medicine, clinical essentials, ed 2, Philadelphia, 2013, Elsevier.

FIGURE EC1-62  Calculi in the common bile duct, casting an acoustic shadow. (From Grainger RG et al [eds]:
Grainger and Allison’s diagnostic radiology, ed 4, Philadelphia, 2001, Churchill Livingstone.)