Gallstones: Summary of NICE guideline

Gallstones may be asymptomatic or symptomatic. There are a number of different presentations of gallstones....
Abdelwahab Ward, BS Pharm, PharmD

INTRODUCTION ã…¡ Gallstones may be asymptomatic or symptomatic. There are a number of different presentations of gallstones – this is important because management differs. More common, (1) Biliary colic – persistent right upper quadrant pain in the absence of fever; may also report intolerance of fried or fatty foods which can trigger pain, nausea, bloating and flatulence/frothy stools. (2) Acute cholecystitis – as above but with fever. (3) Asymptomatic gallstones found on abdominal ultrasound performed for other reasons. Less common, (1) Acute pancreatitis – epigastric pain radiating to back; nausea, vomiting. (2) Obstructive jaundice – usually with pain. (3) Acute cholangitis – ascending biliary tree infection; usually presents with jaundice, fever, rigors = unwell!.. No causative link has been found between gallstones and gallbladder cancer, though they may share common risk factors.

DIAGNOSIS

Investigations. Use ultrasound and liver function tests (LFTs) to diagnose gallbladder stones in patients with symptoms suggestive of gallstone disease. These investigations are also recommended for patients with abdominal/gastrointestinal symptoms that are unresponsive to previous management because symptoms of gallstones may be vague. LFTs are useful in predicting common bile duct stones. Ultrasound is recommended as a first-line investigation because it is accurate, widely available and low risk.

Magnetic resonance cholangiopancreatography (MRCP) should be considered if ultrasound has not shown common bile duct (CBD) stones and there are abnormal LFTs or a dilated CBD. Endoscopic ultrasound should be considered as a third-line investigation if a diagnosis has still not been made after MRCP.

MANAGEMENT

Management depends on where the gallstones are located (gallbladder or common bile duct) and whether symptomatic/asymptomatic. 

Asymptomatic gallbladder stones. These are gallbladder stones that are found incidentally as a result of imaging investigations unrelated to gallstone disease in people who have been completely symptom-free for at least 12m. There was no evidence to inform recommendations for management so these are based on consensus opinion. There is currently no way of predicting which patients will develop complications. NICE considered dissolution therapy, lithotripsy, cholecystectomy and a watch and wait approach. 

          For people with asymptomatic gallbladder stones in a normal gallbladder who have a normal biliary tree. NICE concluded that most people will not go on to develop complications, so the risks of intervening outweigh the risks of not treating: reassure these patients they do not need treatment unless they develop symptoms. Further investigation is needed if there are abnormalities of the gallbladder/biliary tree – refer.

Asymptomatic common bile duct stones. The guideline development group considered that the complications from common bile duct stones (e.g. pancreatitis, cholangitis) are more likely to be life-threatening than for gallbladder stones. The risks of leaving these stones therefore outweighs the risks of treatment, so they should be managed as for symptomatic gallstones stones. 

Symptomatic gallstones. These are gallstones diagnosed on imaging in people who have had any symptoms in the past 12m. Patients should be offered a laparoscopic cholecystectomy (this should be within 7 days of an episode of acute cholecystitis). Percutaneous cholecystostomy can be used for gallbladder empyema when surgery is not appropriate and conservative management has failed. Laparoscopic cholecystectomy can then be reconsidered once the person is well enough to have surgery. 

Common bile duct stones should be cleared either before or at the time of laparoscopic cholecystectomy. If stones cannot be cleared with Endoscopic retrograde cholangiopancreatography (ERCP), temporary biliary stenting should be used pending definitive endoscopic or surgical clearance. Advise avoiding food or drink that triggers symptoms until the gallbladder/gallstones are removed. AND review patients with a recurrence of or new symptoms triggered by food or drink after recovery from surgery, and consider other diagnoses.

NICE is clear in its guideline that ALL with symptomatic gallstones should be offered laparoscopic cholecystectomy. A BMJ Uncertainties article questioned if this should be the case for all (BMJ 2019;367:l5709), available at:  https://www.bmj.com/content/367/bmj.l5709.

There is limited evidence from two small trials (total 201 patients) that conservative management may be a safe alternative for some patients if they have acute cholecystitis/biliary colic and no complications (complications such as perforation/gangrene of gallbladder, acute cholangitis, obstructive jaundice, acute pancreatitis, severe acute cholecystitis or empyema). 55% of patients randomised to conservative management did not require surgery over a 14y period. This is unlikely to change our practice in primary care; we should still refer. We may see a conservative approach by secondary care for a select subsection of our patients.

REFERENCES

Abdelwahab Ward, BS Pharm, PharmD