Cholelithiasis

Cholelithiasis is the presence of calculi within the gallbladder. Most gallstones are cholesterol stones, with pigment stones accounting for the remainder.

Gallstone formation is promoted by cholesterol supersaturation, gallbladder stasis and crystal nucleation. Pigment stones are associated particularly with chronic haemolysis, biliary infection and altered bilirubin metabolism.

Most gallstones remain asymptomatic. Clinically important disease begins when stones produce biliary pain or complications such as acute cholecystitis, choledocholithiasis, ascending cholangitis, gallstone pancreatitis, gallstone ileus or Mirizzi syndrome.

The presence of gallstones alone is not an indication for cholecystectomy.

Asymptomatic gallstones are commonly discovered incidentally.

Symptomatic cholelithiasis classically causes episodic right upper quadrant or epigastric pain after transient cystic duct obstruction. Pain may radiate to the right scapula or back and is often associated with nausea.

Persistent pain, fever or systemic inflammatory features suggest a complication rather than uncomplicated gallstones.

Jaundice is not a feature of isolated gallbladder stones and should prompt assessment for common bile duct obstruction, cholangitis or another hepatobiliary disorder.

Right upper quadrant ultrasound: first line investigation; demonstrates gallstones and simultaneously assesses the gallbladder and biliary tree.

Check liver biochemistry when symptoms suggest gallstone disease. Elevated bilirubin or cholestatic liver enzymes, a dilated common bile duct or pancreatitis should trigger assessment for choledocholithiasis.

MRCP or endoscopic ultrasound is appropriate when common bile duct stones remain clinically suspected despite inconclusive ultrasound.

Asymptomatic gallstones in a normal gallbladder generally require observation rather than prophylactic surgery.

Symptomatic gallstones should undergo elective laparoscopic cholecystectomy because recurrent biliary pain and future gallstone complications are common once symptoms begin.

Routine antibiotics are unnecessary for uncomplicated symptomatic cholelithiasis.

During laparoscopic cholecystectomy, obtain the critical view of safety before dividing the cystic duct or artery:

• Clear fibrofatty tissue from the hepatocystic triangle
• Separate the lower gallbladder from the cystic plate
• Confirm that only two structures enter the gallbladder

Do not continue hazardous dissection when anatomy cannot be defined safely. A subtotal cholecystectomy is preferable to bile duct injury in a severely scarred or hostile hepatocystic triangle.

Suspected common bile duct stones require duct clearance, either by ERCP or operative bile duct exploration, combined with definitive cholecystectomy.

Gallstone dissolution therapy has a very limited role because treatment is slow, recurrence is common and most symptomatic surgical candidates are better treated definitively with cholecystectomy.