Official reprint from UpToDate

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2012 UpToDate

Author
Nezam H Afdhal, MD, FRCPI
Section Editor
Sanjiv Chopra, MD
Deputy Editor
Anne C Travis, MD, MSc, FACG
Approach to the patient with incidental gallstones
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2012. | This topic last updated: Aug 26, 2011.
INTRODUCTION Gallstone disease is one of the most common and costly of all digestive diseases.
(See "Epidemiology of and risk factors for gallstones".)
This topic will review the approach to the patient with an incidental finding of gallstones. The approach to
patients with symptomatic gallstones or with complications of gallstone disease (such as cholecystitis and
pancreatitis) is discussed separately. (See "Uncomplicated gallstone disease" and "Pathogenesis, clinical
features, and diagnosis of acute cholecystitis" and "Approach to the patient with suspected
choledocholithiasis" and "Clinical manifestations and diagnosis of acute pancreatitis" and "Etiology of
acute pancreatitis", section on 'Gallstones'.)
NATURAL HISTORY OF ASYMPTOMATIC GALLSTONES A great deal has been learned about the
epidemiology of and risk factors for gallstones (table 1). Ultrasonography has played a major role in this
process, providing a rapid, risk-free method of screening large populations. Prior to the availability of
ultrasound, most studies relied on highly selective autopsy data and limited oral cholecystography.
The routine use of ultrasonography for the evaluation of abdominal pain, pelvic disease, and abnormal
liver function tests has led to the identification of incidental gallstones in many patients (table 2) [1-5]. The
majority of these patients have no symptoms attributable to the gallstones; however, approximately 20
percent will become symptomatic during up to 15 years of follow-up [1-3]. The likelihood of continued
symptoms or the development of other complications of gallstone disease (such as cholecystitis,
pancreatitis, and choledocholithiasis) is substantially higher in patients who have developed symptomatic
gallstones. (See "Uncomplicated gallstone disease", section on 'Biliary colic'.)
In a landmark study, for example, the entire population of a town in Italy (Sirmione) was screened by
ultrasound for the presence of gallstones or gallstone related disease [2]. Of 132 subjects with gallstones
who were identified, the following observations were made:
The overall prevalence of gallstones was 7 percent, was higher in women than men (9 versus 5
percent), and increased with advancing age.

Patients with gallstones were significantly more likely to suffer from biliary pain compared with
patients without gallstones (22 versus 2 percent).

Eighty-two percent of patients found to have gallstones were not aware of having gallstones prior to
the study; 16 percent of these patients developed symptoms during 10 years of follow-up.

Similar findings were reported in a cross-sectional study in Rome that included 151 patients who were
identified as having gallstones by ultrasound [4]. At study entry, 22 percent had symptoms attributable to
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gallstone disease. During 10 years of follow-up, the cumulative probability of developing biliary colic
among the asymptomatic individuals was 26 percent.
The prevalence of gallstones and gallstone related disease in the United States was estimated based
upon data from the third National Health and Nutrition Examination Survey (NHANES III), in which
gallbladder ultrasonography was performed in a representative sample of more than 14,000 people [5].
The overall prevalence of gallstones and gallbladder disease (ie, either the presence of gallstones or
ultrasonographic evidence of cholecystectomy) was 5.5 and 7.9 percent respectively in men, and 8.6 and
16.6 percent, respectively in women. As expected, the prevalence varied depending upon age and
ethnicity. The prevalence of gallstones and gallbladder disease was highest in men and women between
the ages of 60 to 74 (table 2), and among Mexican Americans compared with non-Hispanic whites and
blacks.
In a study from Norway, 1371 randomly selected patients who had not had a cholecystectomy underwent
an ultrasound examination. Incidental gallstones were discovered in 285 (21 percent) [6]. Twenty-four
years later, a follow-up study was performed that included 134 of the patients who had gallstones [7]. The
patients underwent either a clinical examination (89 patients) or answered a mail or telephone
questionnaire (45 patients). Gallstones were present on ultrasound in 25 of 89 patients (28 percent
overall, 31 percent of women and 25 percent of men). The mean age of the 89 patients at the time of the
initial examination was 44 years for women and 45 years for men. There was no association between the
number or size of gallstones at the original examination and the demonstration of gallstones at follow-up.
Nine of 134 patients (7 percent) had undergone cholecystectomy, as had 5 of 91 patients who had died
prior to follow-up (6 percent). During follow-up, 44 percent developed abdominal pain, and 29 percent had
what were deemed to be functional abdominal complaints.
Patients who have symptomatic gallstones represent a separate category. These patients are likely to
develop recurrent symptoms, and are at increased risk for the development of complications [8,9]. In an
illustrative study that included 305 patients with gallstones, 70 percent of those with a history of biliary
colic developed recurrent symptoms within two years [8]. Other complications of gallstones disease occur
at a rate of approximately 1 to 2 percent per year in most studies. The majority of patients who present
with these complications have a prior history of biliary colic.
These data demonstrate that the majority of patients found to have incidental gallstones will remain
asymptomatic and that with prolonged follow-up, many patients will not have gallstones demonstrated on
follow-up examination. When symptoms occur, they are usually biliary colic rather than complications of
gallstone disease.
Gallstones are sometimes implicated as the source of symptoms in patients with dyspepsia. However,
such an association should be made cautiously since gallstones may silently coexist in patients with
dyspepsia, and other causes of dyspepsia are more common. (See "Approach to the patient with
dyspepsia" and "Uncomplicated gallstone disease", section on 'Predictive value of symptoms'.)
ROLE OF PROPHYLACTIC CHOLECYSTECTOMY There are no prospective trials of therapy, either
surgical or medical, for asymptomatic gallstones. However, decision analysis models have shown no
benefit of a prophylactic cholecystectomy. In one study, for example, decision analysis was used to
compare the consequences of prophylactic cholecystectomy with expectant management in patients with
asymptomatic gallstones [10]. Prophylactic cholecystectomy slightly decreased survival and was
not associated with an appreciable gain in discounted life years gained. Although this model was
constructed prior to the development of laparoscopic cholecystectomy, it is unlikely that the laparoscopic
approach would significantly alter the results based upon sensitivity analysis included in the study.
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Thus, prophylactic cholecystectomy is not indicated in most patients with asymptomatic gallstones.
Possible exceptions include patients who are at increased risk for gallbladder carcinoma or gallstone
complications, in whom prophylactic cholecystectomy or incidental cholecystectomy at the time of another
abdominal operation can be considered. (See 'Patients at increased risk of complications' below and
"Gallbladder cancer: Epidemiology, risk factors, clinical features, and diagnosis".)
Cholecystectomy is recommended in patients with symptomatic gallstones who are good surgical
candidates. Medical therapy can be considered in symptomatic patients who are not good candidates for
surgery. (See "Uncomplicated gallstone disease", section on 'Management' and "Patient selection for the
nonsurgical treatment of gallstone disease".)
PATIENTS AT INCREASED RISK OF COMPLICATIONS Some patients with asymptomatic
gallstones may be at increased risk from complications and may therefore require special consideration.
Diabetes mellitus Gallstones are more common in diabetic patients. (See "Epidemiology of and risk
factors for gallstones".) Predominantly anecdotal evidence suggests that diabetic patients are at
increased risk for the development of severe gangrenous cholecystitis [11].
However, the magnitude of the risk and the risks and costs of cholecystectomy do not warrant
prophylactic cholecystectomy in diabetics with asymptomatic gallstones. One study, for example,
identified 70 patients with gallstones and diabetes mellitus who were followed for five years; 47 (70
percent) were asymptomatic at study entry, while the others had a history of biliary colic [12]. During
follow-up, 10 percent of the initially asymptomatic patients developed biliary colic and 4 percent
developed other gallstone complications; these values are similar to the general population [1-3]. By
contrast, 48 percent of patients who were initially symptomatic either continued to have biliary colic (40
percent) or developed acute cholecystitis (8 percent).
Patients at increased risk for biliary cancer An increased risk of cholangiocarcinoma and
gallbladder carcinoma has been associated with certain disorders of the biliary tree, and in some ethnic
groups (such as Native Americans). (See "Epidemiology, pathogenesis, and classification of
cholangiocarcinoma" and "Gallbladder cancer: Epidemiology, risk factors, clinical features, and
diagnosis".) These include:
Choledochal cysts (see "Biliary cysts")
Caroli's disease (see "Caroli disease")
Anomalous pancreatic ductal drainage (in which the pancreatic duct drains into the common bile
duct)

Gallbladder adenomas (see "Gallbladder polyps and cholesterolosis")

Porcelain gallbladder (see "Porcelain gallbladder")
Prophylactic cholecystectomy may be indicated in many of these patients. If abdominal surgery is planned
for another indication, an incidental cholecystectomy should be performed [13,14].
Sickle cell disease Pigment gallstones are common and often asymptomatic in patients with sickle
cell disease. Prophylactic cholecystectomy is not recommended, but an incidental cholecystectomy
should be considered if abdominal surgery is being performed for other reasons. (See "Overview of the
clinical manifestations of sickle cell disease".)
Hereditary spherocytosis Some authorities recommend combined prophylactic splenectomy and
cholecystectomy in young asymptomatic patients with hereditary spherocytosis if gallstones are present.
(See "Hereditary spherocytosis: Clinical features; diagnosis; and treatment", section on 'Gallstone
formation'.)
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Gastric bypass surgery Morbidly obese patients who have undergone gastric bypass surgery, a form
of bariatric surgery, have a high incidence of developing gallstones (greater than 30 percent) [15,16]. An
incidental cholecystectomy is recommended by some at the time of surgery, though the issue is
controversial. (See "Epidemiology of and risk factors for gallstones", section on 'Rapid weight loss' and
"Complications of bariatric surgery", section on 'Cholelithiasis'.)
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The
Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at
the 5
th
to 6
th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated,
and more detailed. These articles are written at the 10
th
to 12
th
grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on "patient info" and the keyword(s) of interest.)
Basics topics (see "Patient information: Gallstones (The Basics)" and "Patient information:
Gallbladder removal (cholecystectomy) (The Basics)")

Beyond the Basics topics (see "Patient information: Gallstones (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
The majority of patients found to have incidental gallstones will remain asymptomatic. When
symptoms occur, they are usually biliary colic rather than complications of gallstone disease. (See
'Natural history of asymptomatic gallstones' above.)

The cardinal symptom of gallstones is biliary colic. Biliary colic is a moderately severe crescendo
type pain in the right upper quadrant radiating to the back and right shoulder, which may be
accompanied by nausea. Despite its name, the pain is usually steady and not colicky. Pain may be
brought on after ingestion of fatty foods. (See "Uncomplicated gallstone disease", section on 'Biliary
colic'.)

Gallstones are sometimes implicated as the source of symptoms in patients with dyspepsia.
However, such an association should be made cautiously, since gallstones may silently coexist in
patients with dyspepsia, and other causes of dyspepsia are more common. (See 'Natural history of
asymptomatic gallstones' above.)

We recommend against prophylactic cholecystectomy in most patients with asymptomatic

gallstones (Grade 1B). Possible exceptions include patients who are at increased risk for
gallbladder carcinoma or gallstone complications, in whom prophylactic cholecystectomy or
incidental cholecystectomy at the time of another abdominal operation can be considered. Although
patients with diabetes mellitus may have an increased risk of complications, the magnitude of the
risk does not warrant prophylactic cholecystectomy. (See 'Role of prophylactic
cholecystectomy' above and 'Patients at increased risk of complications' above.)

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REFERENCES
Capocaccia, L, the GREPCO group. Clinical symptoms and gallstone disease: Lessons from a
population study. In: Epidemiology and prevention of gallstone disease, Capocaccia, L, Ricci, G,
Angelico, F, Attili, AF (Eds), Lancaster MTP Press, 1984. p.153.
1.
Barbara L, Sama C, Morselli Labate AM, et al. A population study on the prevalence of gallstone
disease: the Sirmione Study. Hepatology 1987; 7:913.
2.
Gracie WA, Ransohoff DF. The natural history of silent gallstones: the innocent gallstone is not a
myth. N Engl J Med 1982; 307:798.
3.
Attili AF, De Santis A, Capri R, et al. The natural history of gallstones: the GREPCO experience.
The GREPCO Group. Hepatology 1995; 21:655.
4.
Everhart JE, Khare M, Hill M, Maurer KR. Prevalence and ethnic differences in gallbladder disease
in the United States. Gastroenterology 1999; 117:632.
5.
Glambek I, Kvaale G, Arnesj B, Sreide O. Prevalence of gallstones in a Norwegian population.
Scand J Gastroenterol 1987; 22:1089.
6.
Schmidt M, Hausken T, Glambek I, et al. A 24-year controlled follow-up of patients with silent
gallstones showed no long-term risk of symptoms or adverse events leading to cholecystectomy.
Scand J Gastroenterol 2011; 46:949.
7.
Thistle JL, Cleary PA, Lachin JM, et al. The natural history of cholelithiasis: the National
Cooperative Gallstone Study. Ann Intern Med 1984; 101:171.
8.
Friedman GD, Raviola CA, Fireman B. Prognosis of gallstones with mild or no symptoms: 25 years
of follow-up in a health maintenance organization. J Clin Epidemiol 1989; 42:127.
9.
Ransohoff DF, Gracie WA, Wolfenson LB, Neuhauser D. Prophylactic cholecystectomy or expectant
management for silent gallstones. A decision analysis to assess survival. Ann Intern Med 1983;
99:199.
10.
Reiss R, Nudelman I, Gutman C, Deutsch AA. Changing trends in surgery for acute cholecystitis.
World J Surg 1990; 14:567.
11.
Del Favero G, Caroli A, Meggiato T, et al. Natural history of gallstones in non-insulin-dependent
diabetes mellitus. A prospective 5-year follow-up. Dig Dis Sci 1994; 39:1704.
12.
Bragg LE, Thompson JS. Concomitant cholecystectomy for asymptomatic cholelithiasis. Arch Surg
1989; 124:460.
13.
Diehl AK. Gallstone size and the risk of gallbladder cancer. JAMA 1983; 250:2323. 14.
Shiffman ML, Sugerman HJ, Kellum JM, et al. Gallstone formation after rapid weight loss: a
prospective study in patients undergoing gastric bypass surgery for treatment of morbid obesity. Am
J Gastroenterol 1991; 86:1000.
15.
Wattchow DA, Hall JC, Whiting MJ, et al. Prevalence and treatment of gall stones after gastric
bypass surgery for morbid obesity. Br Med J (Clin Res Ed) 1983; 286:763.
16.
Topic 673 Version 4.0
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GRAPHICS
Major risk factors for the development of gallstones
Age
Female sex
Genetic
Pima Indians and certain other Native Americans
Chileans
Pregnancy
Obesity
Rapid weight loss
Very low calorie diet
Surgical therapy of morbid obesity
Cirrhosis
Hemolytic anemias
Hypertriglyceridemia
Medications
Estrogen and oral contraceptives
Clofibrate
Ceftriaxone
Octreotide
Terminal ileal resection
Gallbladder stasis
Diabetes mellitus
Total parenteral nutrition
Postvagotomy
Octreotide or somatostatinoma
Spinal cord injury
Reduced physical activity (at least in men)
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The prevalence of gallstone disease (GSD) in selected populations
Population Test Age
Female
percent GSD
Male percent
GSD
Mexican-
American
1982-1984
(n = 1388)
Ultrasonography 20-
39
13.8 2.6
40-
59
26.4 9.7
60-
74
44.4 15.5
Puerto Ricans
1982-1984
(n = 582)
Ultrasonography 20-
39
9.0 2.0
40-
49
21.2 3.3
60-
74
12.1 11.1
Rome, Italy
1981-1982
(n = 2320)
Ultrasonography 20-
29
2.5 2.3
30-
39
5.9 2.0
40-
49
10.9 6.7
50-
59
17.8 14.7
>65 25 14.4
Bristol,
England*
1987-1989
(n = 1896)
Ultrasonography 20-
29
3.9 -
30-
39
6.4 -
40-
49
6.5 4.7
50-
59
14.2 22.4
60-
69
22.4 11.5
Pima Indians
1967-1968
(n = 596)
Oral
cholecystogram
15-
25
12.7 0
25-
34
73.2 4.4
35-
44
70.8 11.1
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45-
54
75.8 31.9
55-
64
62.0 66.3
>65 89.5 67.8
Okinawa,
Japan-
1984
(n = 2727)
Ultrasonography 0-19 0 1.0
20-
29
3.0 1.0
30-
39
3.5 2.5
40-
49
3.0 2.0
50-
59
4.0 1.5
60-
69
9.0 4.5
>70 9.5 15.0
United StatesA
1988-1991
(n = 14,000)
Ultrasonography 20-
29
4.4 1.3
30-
39
5.2 1.1
40-
49
8.2 5.9
50-
59
11.9 7.3
60-
74
16.4 17.2
* Adapted from Heaton, IW, Braddon, FEM, Mountford, RA, et al, Gut 1991; 32:316.
- Adapted from Nomura, H, Kashiwagi, S, Hayashi, J, et al. Am J Epidemiol 1992; 136:787.
A Adapted from Everhart, JE, Khare, M, Hill, M, Maurer, KR. Gastroenterology 1999; 117:632.
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