Page created on September 11, 2021. Last updated on April 12, 2022 at 15:39

Gallstone disease

Introduction

For introduction, epidemiology, etiology, pathomechanism, see the corresponding topic in pathology 2. For clinical features, and diagnosis and evaluation, see the corresponding internal medicine topic (69).

Management

Conservative treatment with analgesics, antibiotics, nothing by mouth, and IV fluids is important. The definitive treatment for gallstone disease is antibiotic treatment and cholecystectomy. Cholecystectomy is almost always performed laparoscopically. There are two approaches to the timing of cholecystectomy, early surgery and delayed surgery.

In most cases, we opt for delayed surgery. In that case, the patient is treated conservatively, and if they respond to this the surgery is delayed for 6 – 8 weeks, after the acute inflammation has resolved. If the patient does not respond to initial conservative therapy, or they have indications for acute surgery like pericholecystic fluid or evidence of gangrene or perforation on imaging, surgery will be performed acutely.

People with only one episode of uncomplicated biliary colic often don’t undergo surgery unless they develop repeated episodes or complications later.

ERCP-guided biliary drainage and stone extraction is the treatment of choice for cholangitis.

Gallstone ileus requires emergency surgery. An enterotomy is made proximal to the stone, and the stone is then removed. Cholecystectomy and fistula closure should be performed at the same occasion or later.

Analgesia is important. The first choice is NSAIDs like ketorolac, diclofenac, or ibuprofen, and the second choice is opioids like morphine or buprenorphine. Many are reluctant to use morphine as it theoretically contricts the sphincter of Oddi, and alternative opioids which cause less constriction (like buprenorphine or meperidine) are often used instead. However, systematic revies have found that all opioids cause sphincter constriction, and there is no evidence that morphine is worse than other opioids in this regard.