Gallstone disease (Guidelines)

Gallstone disease pathway 

From 2016 RCSEng/AUGIS Commissioning Guide.

Gallstones on abdominal USS

No treatment or referral

CBD stone 

Routine referral due to the risk of potentially significant complications. 
(If the patient is currently asymptomatic but there has been a history of jaundice or infection consider urgent referral)

First presentation 

Most patients with symptomatic gallstones present with a self-limiting attack of RUQ / epigastric pain, frequently radiating to the back +/- nausea/vomiting.

This can usually be controlled in primary care with appropriate analgesia +/- anti-emetics without hospital admission.

Consider checking LFTs and a routine referral for USS (although may be deferred until symptoms become recurrent – please see below)

When pain cannot be managed or if the patient is otherwise unwell (septic), refer as an emergency to the on-call surgical team

Recurrent symptoms

Further episodes of biliary colic are common (50% risk per annum with 1 to 2% risk per annum of complications).

If not done following the initial presentation, arrange for LFTs to be checked and request a routine USS (unless LFTs are significantly abnormal or the patient is clinically jaundiced. (See section: Clinical suspicion of biliary obstruction)

Recurrent episodes can be prevented in around 30% of patients by adopting a low-fat diet (fat in the stomach provokes release of cholecystokinin, which precipitates gallbladder contraction).

If gallstones (including the suggestion of gallbladder sludge) are confirmed on USS, and the patient is considered fit for and would desire surgery, refer routinely for consideration of cholecystectomy

If the gallbladder is normal with no gallstones identified, consider an alternative diagnosis e.g dyspepsia.

There is NO evidence to support the use of:

• Antibiotics in the absence of signs of sepsis
• Any particular medications beyond analgesia and anti-emetics for symptom control, e.g PPIs (although biliary colic can sometimes give dyspepsia-type symptoms)
• Non-surgical treatments in the definitive management of gallstones (e.g. gallstone dissolution therapies, ursodeoxycholic acid or extracorporeal lithotripsy)

(with or without known gallstones)

Ideally patient with acute cholecystitis should have a cholecystectomy in the same admission but if the patient is clinically well and admission is not felt to be required based on clinical condition, management of cholecystitis in the community with analgesia and anti-emetics may be appropriate. If in doubt a discussion with the on-call surgical team would be appropriate.

In the case of management in Primary Care

• Please see antimicrobial guidelines (see resources) for up to date recommended antibiotics (at time of writing oral co-trimoxazole 960mg twice daily PLUS oral metronidazole 400mg 3 times daily).
• Refer for outpatient surgical review (routine) if patient is fit for surgery

If the patient cannot be managed in the community, refer the patient to the on-call surgeon with view to admission.

(with or without known gallstones)

If there is a clinical suspicion of acute pancreatitits or cholangitis, refer the patient to the on-call surgical team.

Patients with known gallstones and jaundice or clinical suspicion of biliary obstruction (e.g. significantly abnormal LFTs), not requiring same day admission (i.e not septic), should be referred urgently.