Review Question - QID 104816

This patient has an asymptomatic gallstone as demonstrated by her ultrasound with no associated symptoms. No treatment is indicated for asymptomatic gallstones.

Cholelithiasis (gallstones) form in the gallbladder from a concentration of bile components. Cholelithiasis often occurs in the "Fat, Forty, and Fertile" demographic but can occur outside of this as well. Gallstones may be asymptomatic for years or can present with acute episodes of pain, often characterized by intense right upper quadrant pain, often radiating to the right shoulder, and accompanied by nausea and vomiting. This often occurs following fatty meals when the gallbladder is forced to release bile, agitating the gallstones. In cases of asymptomatic gallstones, no treatment is warranted. In cases of symptomatic gallstones, laparoscopic cholecystectomy may be performed.

Abrahan et al. review the diagnosis and management of gallstones. They state most patients are asymptomatic; gallstones are discovered incidentally during ultrasonography or other imaging of the abdomen. Asymptomatic patients have a low annual rate of developing symptoms (about 2% per year). Laparoscopic cholecystectomy remains the surgical choice for symptomatic and complicated gallstones, with a shorter hospital stay and shorter convalescence period than open cholecystectomy.

Bellows et al. review the management of cholelithiasis. They state many patients with gallstones can be managed expectantly. Generally, only persons with symptoms related to the presence of gallstones or complications (such as acute cholecystitis or gallstone pancreatitis) warrant surgical intervention. Biliary pain is alleviated by cholecystectomy in the majority of cases. Laparoscopic cholecystectomy is considered the most cost-effective management strategy in the treatment of symptomatic gallstones.

Figure A demonstrates a right upper quadrant ultrasound showing a significant gallstone. Illustration A illustrates the mechanism to pain in biliary colic. Illustration B demonstrates the surgical approaches to treatment in biliary colic. Illustration C demonstrates findings of cholecystitis on ultrasound.

Incorrect answers:
Answer 1: Laparoscopic cholecystectomy is reserved for patients with symptomatic cholelithiasis.
Answer 2: Open cholecystectomy is second line treatment for symptomatic cholelithiasis (behind laparoscopic cholecystectomy).
Answer 3: Ursodeoxycholic acid is used primarily to treat primary biliary cirrhosis.
Answer 5: Endoscopic retrograde cholangiopancreatography (ERCP) is often used to remove gallstones that become lodged in the sphincter of Oddi or in the common bile duct and is causing cholangitis or gallstone pancreatitis.