Evaluation and Management of Gallstone: Related Diseases in Non-Pregnant Adults

[2014 new]

Introduction to this self-study CME activity

Purpose

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.

 

Objectives

Participants in this CME activity will understand and be able to implement evidence-based cost-effective clinical strategies for the diagnosis and initial treatment of gallstone-related diseases in adult patients.

Audience

This self-study activity is appropriate for physicians in Emergency Medicine, Family Medicine, Gastroenterology, Internal Medicine, Radiology, Surgery, and other health care providers participating in inpatient or ambulatory care of patients with suspected gallbladder related diseases.

Authors

Team Leaders

  • Hasan B. Alam, MBBS
    Surgery
  • Farokh R. Demehri, MD
    Surgery

Team Members

  • Suzanne T. Chong, MS, MD
    Radiology
  • Steven L. Kronick. MS, MD
    Emergency Medicine
  • William T. Repaskey, MD
    Internal Medicine
  • Michael David Rice, MD
    Gastroenterology
  • F. Jacob Seagull, PhD
    Medical Education

Author Disclosures

Neither the team lead, the team members, nor the consultants have financial relationships with commercial companies whose products are discussed in this CME activity.

Other Acknowledgements

UMHS Guidelines Oversight Team

  • Sarah E. Hartley, MD
  • Megan R. Mack, MD
  • David H. Wesorick, MD
  • F. Jacob Seagull, PhD

Literature Search Services

  • Taubman Medical Library

Production of Internet Format and Website Maintenance

  • Ellen Patrick-Dunlavey, MA

CME Accreditation and Credit Designation

The University of Michigan Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Michigan Medical School designates this enduring material for a maximum of 1 AMA/PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This CME activity was released in March 2015 with credit available through February 2018. The activity was reviewed for currency of content in February 2018 and availability of credit extended through August 2021. Continuation of credit from that date depends on a thorough review of the content currency and accuracy.

Method of Participation

  1. View the web pages. You may print the self-study text to read off-line.
  2. Complete the on-line learning assessment test with a score of 70% or higher.  After you initially take the test, the test will be immediately electronically scored. 
    If fewer than 70% of the questions are answered correctly, the questions that were not answered correctly will be noted in red.  Review the CME content related to those topics and retake the test.
    If 70% or more of the questions are answered correctly, the correct and incorrect answers for all questions will be shown along with explanations of the basis for the correct answer.  The link to register and receive credit is shown at the end of the items and explanations. 
  3. Complete the electronic credit request and activity evaluation.  An electronic certificate of participation will be provided immediately.
  4. Print the certificate of participation for your personal records.