Evaluation and Management of Gallstone: Related Diseases in Non-Pregnant Adults [2014 new]

Description: Gallbladder disease is common, with over 700,000 cases annually of gallstones alone in the US, and 10-15% incidence in white adults in developed countries. Risk factors for gallstones include female gender, increasing age, obesity, metabolic syndrome, and rapid weight loss. It is a common reason for hospitalization, and its management is uniquely multidisciplinary, involving emergency medicine, internal medicine, gastroenterology, radiology, and general surgery. Quality of care can be compromised by delays in treatment. Unnecessary testing can cause delays, and also can incur costs, increase length of stay, and may not change the care plan.

This clinical practice guideline is intended to enhance consistency in patient management, facilitate interdisciplinary consensus, increase efficiency of patient care, and improve clinical outcomes. This guideline is not comprehensive, but can guide the care of the majority of patients with gallstone-related disease.

Diagnosis
The evaluation for gallstone-related disease routinely includes:

1. Complete physical exam
2. Laboratory evaluation – CBC, comprehensive metabolic panel, amylase/lipase
3. Imaging – Right upper quadrant (RUQ) ultrasound

In the vast majority of patients with acute cholecystitis, the diagnosis can be made based upon the history, physical findings, laboratory tests, and ultrasound (see Table 3 for the ultrasound findings that are suggestive of acute cholecystitis). In cases where the diagnosis of cholecystitis remains uncertain after this evaluation, additional imaging modalities may be necessary.

This CME activity addresses the diagnosis and initial treatment of gallstone-related diseases in adult patients. This document does not provide detailed recommendations for the general care of patients with acute pancreatitis.

Problem: Gallbladder disease is common, with over 700,000 cases annually of gallstones alone in the US, and 10-15% incidence in white adults in developed countries. Risk factors for gallstones include female gender, increasing age, obesity, metabolic syndrome, and rapid weight loss.

Treatment
Biliary Colic

1. Minimally symptomatic or with symptoms that resolve: Provide reassurance, education on avoidance of triggers (e.g. dietary fat). Provide direct referral to elective surgery.
2. Moderate to severe symptoms: Consult surgery. Perform non-urgent laparoscopic cholecystectomy during same visit. Timing of surgery determined by patient preference and operating room availability.

Acute Cholecystitis

1. Admit to Surgery.
2. Initiate IV antibiotics.
3. Perform laparoscopic cholecystectomy within 24-48 hours.

In patients without gallstones who have RUQ and/or epigastric pain and a HIDA scan showing delayed gallbladder filling or lack of gallbladder emptying, cholecystectomy should be recommended.
Choledocholithiasis

1. Evaluate for evidence of cholangitis. If suspected, treat as cholangitis (below).
2. If no evidence of cholangitis, admit to surgery and prepare for cholecystectomy.

Cholangitis

1. Admit to Medicine service.
2. Initiate IV antibiotics, NPO.
3. Obtain Gastroenterology consult.
4. Classify severity of acute cholangitis.
   • If mild cholangitis with adequate response to medical therapy: ERCP within 72 hours.
   • If moderate-severe and not responsive to medical therapy: ERCP within 24 hours.
5. Consult surgery for laparoscopic cholecystectomy during same admission, after cholangitis resolves.

Gallstone Pancreatitis

1. Evaluate for evidence of cholangitis. If suspected, treat as cholangitis (above).
2. Classify severity of gallstone pancreatitis.