A significant number of patients with cholelithiasis do not have postprandial pain but instead have dyspepsia, vague upper gastric discomfort, or even mildly increased flatulence as primary symptoms (1).

There are three types of gallstones: cholesterol, pigmented, and mixed. Approximately 10% of stones are pure cholesterol, 15% are pigmented, and the remaining 75% are mixed (1).

A study in the 1990s looked at the clinical significance of gallbladder sludge. Diagnosis of gallbladder sludge was made by ultrasound in 286 patients followed up for a mean of 20 months. Although sludge disappeared spontaneously within a relatively short time in 71% of the patients, gallbladder sludge was significant because cholelithiasis or other complications occurred in 19% of the patients. Acute calculus cholecystitis developed in 7.1% of the patients (5).

An increased incidence of gallstone disease has been observed in elderly patients, certain ethnic groups, women, immediate family members of a patient with cholelithiasis, obese patients, diabetic patients, cirrhotic patients, patients with truncal vagotomy, and patients receiving long-term total parenteral nutrition (1).

Asymptomatic patients with gallstones generally have a benign course. Approximately 2% of asymptomatic patients with gallstones develop symptoms every year. One study of 123 patients with asymptomatic cholelithiasis and an actuarial follow-up period of up to 20 years showed that only 5.7% of these patients developed severe complications, including obstructive jaundice, acute cholecystitis, gallstone ileus, and pancreatitis. Only 13% eventually developed mild symptoms that required elective cholecystectomy (2,6,7).

A prospective study of non-insulin-dependent diabetic patients who were followed for 5 years showed that a cumulative percentage of 10.8% of patients developed symptoms and 4.2% developed complications (9). Another prospective review comparing diabetic and nondiabetic patients who underwent cholecystectomy did not show a difference in the incidence of perforation, wound infection, overall morbidity, or mortality (1). Therefore, in general, prophylactic cholecystectomy in an asymptomatic diabetic patient may not be recommended (2,10). However, it is important to consider individual factors such as age and comorbidities, and surgery may be appropriate in selected asymptomatic diabetic patients.

Possible complications include acute cholecystitis, obstructive jaundice, acute cholangitis, gallstone ileus, and gallstone pancreatitis. Less than 1% of patients with initial complication of cholelithiasis have a fatal outcome during that hospitalization (1).

ESWL is usually combined with oral bile acid dissolution. Complete stone clearance rates vary from 60% to 90%. The factors that determine the complete clearance of the stones are the isodensity with bile and the computed tomography (CT) score (Hounsfield units below 75). The main causes of failure are acquired stone calcification and impaired gallbladder motility (11). When calculated by actuarial analysis, the probability of stone recurrence has been 5.5% to 7% after 1 year, 11% to 12% after 2 years, 13% after 3 years, 20% after 4 years, and 31% after 5 years (11,12).

Gallbladder emptying is an important factor in the recurrence of gallstones. One study showed that the recurrence rate was 53% at 3 years when the gallbladder ejection fraction was less than 60% but only 13% in patients with an ejection fraction above 60% (13). The cumulative risk of gallstone recurrence by actuarial analysis has been shown, after complete direct contact dissolution with MTBE, to be as follows (14):

These modalities are indicated for symptomatic patients who are poor risks for laparoscopic cholecystectomy. Most protocols for ESWL are limited to symptomatic patients with one to three radiolucent stones with a diameter of 30 mm or less and a functioning gallbladder according to CCK hepatobiliary iminodiacetic acid (CCK HIDA) scan. ESWL is safe and effective for patients with a single stone not more than 20 mm in diameter, but the efficacy for larger single stones and multiple stones is poor (12,14,15). Long-term use of ursodeoxycholic acid is associated with reduced risk of biliary pain and acute cholecystitis (16).

The preferred method of treating symptomatic gallstones is laparoscopic cholecystectomy. It has the advantages of little postoperative discomfort, short hospital stay, and short postoperative disability. This procedure can be performed safely with an overall morbidity that ranges from 3% to 10%, and mortality rates are 0 to 0.1%. Injury to the bile ducts occurs in 0.2% to 0.6% of patients undergoing this procedure. The incidence of complication decreases with increased surgeon experience and with careful attention to laparoscopic surgical technique. The incidence of major bile duct injury can decrease to rates comparable with those of open cholecystectomy.

CBD stones are found in 8% to 15% of patients undergoing cholecystectomy for symptomatic cholelithiasis (1). The incidence seems to be greater in patients older than 60 years of age (25%).

This topic is controversial. Advocates of routine intraoperative cholangiography during laparoscopic cholecystectomy argue that this practice gives a better definition of the anatomy by providing a road map for the surgeon and by identifying anomalous insertion of the cystic duct or other anatomic aberrations of the bile ducts. Only those performing it routinely become proficient in cannulating the cystic duct and in interpreting the fluoroscopic images. Also, a routine intraoperative cholangiogram enables the surgeon to detect an injury to the bile tract early during operation, allowing a prompt repair and reducing the morbidity associated with delayed diagnosis and repair of injuries made to major bile ducts (2,16).

Other surgeons argue against the routine use of cholangiography because they say it is too technical, it wastes time and expense, there are false-positive studies (4%), and it has not been proven that routine intraoperative cholangiography prevents bile duct injury (1,16,17). A retrospective nationwide cohort analysis of Medicare patients undergoing cholecystectomy and a retrospective population-based cohort study looking at the Washington State Hospital discharge database showed that the rate of CBD injury was significantly lower when intraoperative cholangiography was used. Use of intraoperative cholangiography does not, however, completely prevent injuries (18,19).

An intraoperative cholangiogram should be performed if there is cholangitis or pancreatitis or a history thereof; if preoperative evaluation shows a dilated or thick CBD; if there are multiple small stones in the gallbladder and the cystic duct; or if the liver function tests are abnormal. An intraoperative cholangiogram is also performed if the surgeon is unable to identify all the structures of the triangle of Calot.

The patient may have acute cholecystitis or biliary colic. Biliary colic causes pain that reaches a plateau lasting minutes to hours. In patients with acute cholecystitis, the pain persists after several hours and may last days. With time, the pain tends to localize more in the right upper quadrant because of the inflammation irritating the peritoneum (1).

It is believed that the initial inflammatory process is a biochemical phenomenon as opposed to an infectious event. The mediators that have been shown to cause cellular injury and inflammation are the bile acids, lithogenic bile, pancreatic juice, lysolecithin, phospholipase A, and prostaglandins. The bacterial invasion is a secondary process (1).

A classic physical sign of cholecystitis, Murphy’s sign is elicited by pressing the right upper quadrant with one’s hand and asking the patient to inhale. The sign is present when the patient suddenly stops the inspiratory effort because of the exquisitely painful contact of the inflamed gallbladder with the examiner’s hand.

The palpable mass may represent hydrops (mucocele) or a pericholecystic abscess. Hydrops occurs when a gallbladder obstructed by an impacted stone fills with a clear or white mucoid material. The wall usually is not inflamed. The mucoid fluid results from altered secretion of the gallbladder epithelium. Symptoms suggesting cholecystitis may or may not be present (1,2).

In the case of pericholecystic abscess, the patient usually is toxic. Empyema, pus in the lumen of the gallbladder, frequently accompanies this condition. The abscess is secondary to a subacute perforation of the inflamed gallbladder. Intervention in the form of cholecystectomy or cholecystostomy is mandated.

No. A recent retrospective study of 100 consecutive patients suspected of having acute cholecystitis who were seen in the emergency department revealed that only Murphy’s sign had a high sensitivity (97.2%) and a high positive predictive value (93.3%) in diagnosing acute cholecystitis compared with biliary scintigraphy (21). These results are similar to those of another retrospective study of 198 patients, which showed that patients with acute cholecystitis (confirmed at surgery) frequently lacked fever and leukocytosis (22).

No. Because gallstones consist largely of the radiolucent cholesterol pigments, only 15% of them are radiopaque. In contrast, kidney stones are 85% radiopaque, a consequence of the higher composition of calcium in kidney stones.

Emphysema of the gallbladder is a result of infection by gas-producing organisms (e.g., clostridia) and is a surgical emergency. It also may arise from a fistula between the intestine and the gallbladder, allowing air into the latter.

Ultrasound is simple, fast, and 95% accurate for demonstrating gallstones (i.e., cholelithiasis) (20). It cannot, however, demonstrate the acute infection of the gallbladder as well as HIDA (accuracy of ultrasound, 79% to 86%) (21). Ultrasound diagnosis of acute cholecystitis is inferred from the ultrasonic images of thickened wall, pericystic fluid, and the presence of intracavitary sludge or stones, intramural gas, and sloughed mucosal membrane.

However, a radionuclide scan has almost 100% sensitivity for diagnosing acute cholecystitis (23). Intravenously (IV) injected isotopes (e.g., HIDA) are secreted into the bile, revealing the biliary tract. The test is reliable with the serum bilirubin level of up to 8 to 10 mg per dL; above those levels, the reliability decreases. The gallbladder is usually visible within 20 to 30 minutes. Failure to reveal the gallbladder implies obstruction of the cystic duct and infection of the organ. Acute cholecystitis is highly likely if the gallbladder is not visible at 1 hour and is certain if the gallbladder is not visible at 4 hours. Acute cholecystitis is mostly a clinical diagnosis; therefore, ultrasound is an adequate test to demonstrate it in a patient with a high clinical suspicion. In patients whose clinical presentation for acute cholecystitis is equivocal or in whom preoperative diagnosis is mandatory because of a significant surgical risk, HIDA scan is more appropriate because of its higher accuracy.

It can have false-positive results, especially in critically ill patients on total parenteral nutrition with prolonged fasting and in patients with acute pancreatitis.

Yes. Pretreatment with cholecystokinin is helpful in the presence of functional resistance to tracer flow into the gallbladder (24). Administration of IV morphine causes spasm of the sphincter of Oddi, thereby causing reflux of bile with radionuclide in the gallbladder. This technique is recommended when the gallbladder is not visible after 1 hour (24). Morphine also increases the visibility of gallbladder in patients pretreated with cholecystokinin (25).

Because the patient does not have a history of liver disease, the two possible explanations are the presence of a stone or stones in the CBD and Mirizzi’s syndrome.

Mirizzi’s syndrome is characterized by obstruction of the common hepatic duct (CHD) or CBD due to contiguous inflammation in the gallbladder or the cystic duct or to compression of the CHD by an impacted large stone in the adjacent cystic duct. The chronic inflammation can result in a stricture. Mild jaundice is present in up to 20% of patients with acute cholecystitis (1). It is usually the result of contiguous inflammation.

Fistulas are formed frequently between the gallbladder or the CBD and the skin (e.g., biliary cutaneous), duodenum (e.g., cholecystoduodenal), and pleura. Problems with fistulas are infection (e.g., cholangitis from the retrograde infection from the bowel, peritonitis from bile leakage, and infection of the affected organ), electrolyte abnormalities (from the continual loss of electrolytes in the bile, most commonly resulting in hyponatremia), malabsorption syndrome (from the lack of bile, which is critical in the intestinal absorption of fat and fat-soluble vitamins), and gallstone ileus.

The interpretation includes the diagnosis of gallstone ileus, which occurs when a large stone formed in either the gallbladder or the CBD passes through a biliary-enteric fistula. In the intestine, it may cause obstruction at a narrow lumen, most commonly at the ileocecal valve, which causes dilation of the proximal bowel.

Gallstone ileus is treated surgically. The gallstone is removed through a small enterotomy. Concomitant cholecystectomy and repair of the fistula are indicated because the patent biliary-enteric fistula may cause recurrent episodes. However, if the patient is too ill, the definitive therapy may be performed later. Enterolithotomy alone has a mortality rate of 5%, in contrast to a mortality rate of 15% for enterolithotomy and cholecystectomy (1).

Yes. With increasing experience, laparoscopic cholecystectomy can be performed safely with complication rates and mortality rates comparable with those of open surgery for acute cholecystitis (30, 31, 32). Acute cholecystitis has a higher conversion rate and incidence of accidental opening of the gallbladder than does laparoscopic cholecystectomy for chronic disease (32,33).