Key Facts

Gallstone disease is extremely common and represents one of the largest surgical workloads in the UK. Understanding the spectrum from asymptomatic stones to life-threatening complications is essential.

Epidemiology

Prevalence ~10-15% in Western populations. Only ~20-30% become symptomatic over a lifetime. Annual risk of symptoms from asymptomatic stones: ~1-4%. Cholecystectomy is one of the most common elective operations (~70,000/year in England).

Aetiology

Cholesterol stones (~80%): Supersaturation of bile with cholesterol, reduced bile salt concentration, gallbladder stasis. Pigment stones: Black (haemolysis — sickle cell, hereditary spherocytosis); Brown (biliary infection/stasis — found in CBD). Risk factors: Obesity, female sex, age >40, multiparity, rapid weight loss, TPN, fibrates, OCP/HRT, Crohn's disease (terminal ileum — bile salt malabsorption).

Pathophysiology

• Bile composition imbalance → cholesterol crystallisation → stone formation
• Stone impaction in cystic duct → biliary colic (obstruction without infection) or cholecystitis (obstruction + infection)
• Stone migration to CBD → choledocholithiasis → obstructive jaundice, cholangitis, pancreatitis
• Charcot's triad: RUQ pain + fever + jaundice (cholangitis)
• Reynold's pentad: Charcot's triad + confusion + hypotension (suppurative cholangitis — septic shock)

Biliary Colic

• RUQ/epigastric pain (constant, not truly colicky), often post-prandial (fatty food)
• Duration 30 minutes to 6 hours
• May radiate to right shoulder/interscapular region
• No fever, normal WCC/CRP
• Self-limiting once stone disimpacts from cystic duct

Acute Cholecystitis

• RUQ pain + fever + raised WCC/CRP
• Murphy's sign positive: Arrest of inspiration on RUQ palpation
• May have palpable gallbladder (not in chronic cholecystitis — fibrosed)
• Mild derangement of LFTs possible

Choledocholithiasis (CBD Stones)

• Obstructive jaundice (dark urine, pale stools, pruritis)
• Raised bilirubin, ALP, GGT; dilated CBD on US (>6mm)

Ascending Cholangitis

• Charcot's triad: RUQ pain, jaundice, fever/rigors
• Medical emergency — requires urgent ERCP and biliary drainage

Red Flags

• Reynold's pentad — suppurative cholangitis, septic shock
• Generalised peritonism — gallbladder perforation
• Gallstone pancreatitis — raised amylase/lipase

Bedside

• Observations: Temperature, HR, BP

Bloods

• FBC, CRP: Raised WCC/CRP in cholecystitis/cholangitis
• LFTs: Raised bilirubin/ALP/GGT suggests CBD stone; raised ALT in gallstone pancreatitis
• Amylase/lipase: >3× ULN suggests pancreatitis
• Blood cultures: If cholangitis suspected
• Coagulation: If jaundiced (vitamin K-dependent factors may be reduced)

Imaging

• Ultrasound abdomen (first-line): Gallstones, gallbladder wall thickening (>3mm = cholecystitis), CBD dilatation (>6mm)
• MRCP: Non-invasive imaging of biliary tree — for suspected CBD stones
• ERCP: Therapeutic — stone extraction, sphincterotomy, stenting
• CT abdomen: If complications suspected (perforation, abscess, pancreatitis)
• HIDA scan: If acalculous cholecystitis suspected (functional biliary disease)

Biliary Colic

• Analgesia: IM diclofenac 75mg (first-line — more effective than opioids for biliary colic) or IV paracetamol
• Elective laparoscopic cholecystectomy: Definitive treatment; within 6 weeks

Acute Cholecystitis

• IV antibiotics: Co-amoxiclav 1.2g TDS or piperacillin-tazobactam 4.5g TDS
• IV fluids, analgesia, NBM
• Laparoscopic cholecystectomy: Ideally within 1 week of presentation ('hot cholecystectomy') — reduces total hospital stays and complications (CholeS study)
• If unfit for surgery: Percutaneous cholecystostomy (drainage)

CBD Stones

• ERCP: Sphincterotomy and stone extraction → followed by cholecystectomy
• Laparoscopic bile duct exploration: Alternative in experienced centres

Cholangitis

• Sepsis 6 pathway: Antibiotics, fluids, cultures
• Urgent ERCP (within 24 hours) for biliary drainage

Referral Criteria

• Symptomatic gallstones — surgical referral for cholecystectomy
• CBD stones/cholangitis — urgent gastroenterology/surgery for ERCP
• Gallstone pancreatitis — cholecystectomy during same admission or within 2 weeks

• Cholecystectomy: Mortality <0.5%; bile duct injury ~0.3-0.5% (most feared complication)
• Biliary colic: ~70% will have recurrent episodes; ~1-3% annual risk of cholecystitis
• Acute cholecystitis: Mortality ~1% overall; higher in elderly and complicated cases
• Cholangitis: Mortality ~5-10% if treated promptly; higher if delayed
• Post-cholecystectomy syndrome: ~10-40% have persistent dyspepsia or diarrhoea

Complications of Gallstones