Gallstones Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • The management of both symptomatic and asymptomatic gallstones in adults
  • The management of conditions commonly associated with gallstones in adults, such as:
    • common bile duct stones (CBDS)
    • acute cholecystitis
    • acute cholangitis

This guidance does not cover:

  • Gallstones (and associated conditions) in children
  • Acute pancreatitis

Assessment

Signs and Symptoms

Asymptomatic

  • see management section
  • typically found incidentally on imaging
  • become problematic in about:
    • 1-4% of patients within a year
    • 10% of patients within 10 years
    • 20% of patients within 20 years
  • most patients will experience symptoms of biliary colic before developing complications
  • the longer the gallstones remain quiescent, the less likely the patient is to develop complications

Symptomatic

  • biliary colic
    • caused by the gallbladder contracting against an obstructed cystic duct
    • patients present with pain that is:
      • severe - can last from 15 minutes to 24 hours and may wake patient at night
      • intermittent - typically separated by weeks/months
      • located in the right upper quadrant or epigastric region - may radiate to the right scapula, shoulder or, occasionally, retrosternally
    • gradually resolving:
      • resolves when the gallbladder stops contracting, or the cystic duct becomes patent again
      • either spontaneously or with analgesics
      • pain that does not resolve could be indicative of a complication
    • typically brought on by fatty foods
    • sometimes associated with diaphoresis, nausea, and/or vomiting
    • atypically associated with belching, bloating, flatulence, and/or dyspepsia
  • acute cholecystitis or empyema
  • acute pancreatitis
  • common bile duct stones (CBDS)
  • acute cholangitis
  • obstructive jaundice
  • mucocoele of gallbladder
  • gallstone ileus - rare
  • Severe complications affect only 1-3% of symptomatic gallstone patients

History and Examination

History

For symptomatic patients take a thorough history to include details of:

  • symptoms:
    • pain: - onset, severity, site, nature (biliary colic rarely has features of a colic), aggravating and relieving factors
    • nausea and vomiting
    • jaundice
    • fever, chills, or rigors
    • change in bowel habit
    • weight loss
  • previous episodes of biliary colic
  • past history of gallstone disease
  • family history of gallstone disease
  • current medications
Examination

Perform a thorough examination to check for signs of associated complications, such as:

  • signs of:
    • inflammation, e.g. fever
    • an acute abdomen
  • a positive Murphy's sign - indicative of inflammation associated with acute cholecystitis

Uncomplicated biliary colic should reveal normal vital signs and physical examination. Also check for:

  • Charcot's cholangitis triad (or Charcot's triad 2):
    • pain, jaundice, and fever (usually with rigors)
    • indicative of acute cholangitis
  • Courvoisier's 'law':
    • painless jaundice and a palpable gallbladder
    • suggests obstruction from pathology other than gallstones, e.g. pancreatic malignancy

An initial clinical assessment will identify:

  • patients with known gallstone disease who:
    • require urgent surgical assessment for serious complications
    • present with increasingly frequent and painful episodes of biliary colic, for whom conservative therapy has failed and definitive surgical intervention should be considered
  • patients with asymptomatic gallstones who present with atypical symptoms and signs:
    • symptoms should not automatically be attributed to cholelithiasis
    • may require further investigation to exclude other causes of epigastric/right upper quadrant pain, including:
    • gastritis/peptic ulcer disease
    • myocardial ischaemia/infarction (MI)
    • pancreatitis
    • hepatitis
    • inflammatory or neoplastic disease of the colon
    • liver/subphrenic abscess
    • oesophageal spasm
    • irritable bowel syndrome
  • patients who have developed atypical pain and/or non-specific symptoms (e.g. chronic indigestion, vague abdominal pain, bloating, belching) - may merit further investigation

Differential Diagnoses

  • Alternative causes of epigastric/right upper quadrant (RUQ) pain include:
    • gastritis/peptic ulcer disease
    • myocardial ischaemia/infarction (MI)
    • pancreatitis
    • hepatitis
    • inflammatory or neoplastic disease of the colon
    • liver/subphrenic abscess
    • oesophageal spasm
    • irritable bowel syndrome

Red Flags

If there is suspicion of any of the following, consider urgent referral to secondary care Surgical Assessment Unit (SAU):

  • haemodynamic compromise
  • acute abdomen:
    • guarding indicates localised/generalised peritonitis
    • acute intestinal obstruction (rare)
  • acute cholecystitis:
    • persistent right upper quadrant (RUQ)/epigastric pain with marked tenderness
    • a positive Murphy's sign:
    • indicative of inflammation associated with acute cholecystitis
    • elicited by asking the patient to inspire deeply with the examining hand immediately below the right costal margin in the mid-clavicular line
    • an inflamed gallbladder is indicated by patient experiencing pain and catching their breath as the gallbladder descends
  • low-grade pyrexia (high-grade pyrexia may indicate cholangitis)
  • delayed presentation with systematic sepsis from gallbladder abscess (empyema) and rarely perforation
  • complications of common bile duct (CBD) stones:
  • jaundice:
    • gallstones associated with painful jaundice indicates obstruction of the common bile duct by a gallstone migrating from the gallbladder
    • rarely, a large stone resident in the gallbladder may compress the biliary tree to present in a similar fashion (Mirrizi's syndrome)
    • painless jaundice is rarely attributable to gallstone pathology
    • patients may complain of pale stool and/or dark urine
  • acute cholangitis:
    • Charcot's triad of jaundice, RUQ pain, and fever (typically with rigors) is diagnostic
    • indicates super-added infection of the obstructed biliary system
  • acute pancreatitis:
    • profuse vomiting
    • central epigastric pain radiating through to the back
    • difficult diagnosis to make in primary care, but should be considered in all unwell patients with a history of gallstones

Investigations

Undertake the following to aid diagnosis, inform management or prior to referral:

Blood work

  • the majority of patients with episodic biliary colic would demonstrate normal blood results
  • elevated inflammatory markers would make the diagnosis of uncomplicated biliary colic unlikely, and should prompt further investigation
  • however, mildly elevated liver function tests can be associated with gallstones if testing takes place during an episode of acute pain - these should be rechecked at an interval to ensure resolution and exclude other causes

Imaging

  • abdominal ultrasound is the recommended first-line investigation
  • sensitivity varies and is operator dependent, but is generally good (79-99%)
  • ultrasound findings of a thickened gallbladder wall and pericholecystic fluid suggest the presence of acute cholecystitis
  • radionuclide scanning is not useful for the diagnosis of gallstone disease - it has a high sensitivity for the detection of acute cholecystitis but is rarely employed

Management

Asymptomatic management

  • Prophylactic cholecystectomy is not recommended in patients with asymptomatic gallstones as the risks of surgical intervention outweigh the perceived benefits.
  • Consider for a surgical referral if imaging suggests unusual features such as:
    • Porcelain gallbladder
    • Polyps
  • Behavioural modification may reduce the development of symptoms in those with initially asymptomatic gallstones:
    • increased physical activity
    • decreased total calorie intake
    • moderate coffee and nut consumption

Acute episode management

  • management of an acute episode of uncomplicated biliary pain or colic should be directed at controlling symptoms such as pain and nausea
  • most episodes without complications can be managed at home
  • opioid-analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) are both effective for pain management
  • patients may be advised not to eat during the acute episode to reduce cholecystokinin-mediated gallbladder contraction
  • episodes lasting more than 24 hours or associated with fever should be referred to hospital - suggests acute cholecystitis
  • Encourage lifestyle changes to possibly decrease risk of further episodes of biliary colic:
    • increased physical activity
    • decreased total calorie intake
    • moderate coffee and nut consumption

Referral

Referral Criteria

  • Red Flags - refer urgently to on-call surgical team
  • Refer to an upper gastrointestinal (GI) surgeon for elective laparoscopic cholecystectomy if:
    • patient expresses desire to undergo surgery
    • patient is medically fit for surgery
  • NB: Preoperative and anaesthetic assessment should identify those who are suitable in borderline cases

Referral Instructions

  • e-Consultation is currently unavailable for this specialty
  • Referral to on-call surgical team - Contact hospital directly
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referral to upper GI - Refer using the eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Signpost patient to Gallstones Decision Making aid which can be printed off for the patient if required

Patient information/Public Health/Self Care


Assurance & Governance

  • This guidance was developed on: 04.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 05.2017
  • Publication Date: 05.2017
  • Review Date: 04.2019
  • Ref No: GS2 - 04.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

Home > Care Pathways > General Surgery* > Gallstones Care Pathway