Clinical presentation of gallstone disease

Gallstone patients may present as:

• asymptomatic
  • approximately 50-70% of patients with gallstones are asymptomatic at the time of diagnosis (1)
  • usually patients becomes symptomatic after many years, once stones reach a certain size (>8mm) (1)
• symptomatic and/or with complication - around 1-2% of patients with cholelithiasis develop the following symptoms or complications per year:
  • biliary colic
    • is the main symptom of uncomplicated cholelithiasis and is present in around 56% of patients (3)
    • caused when the gallbladder contracts against an outlet obstruction (obstruction of the gall bladder neck or the cystic duct by a stone)
    • severe and cramping right upper quadrant abdominal pain which may radiate round to the back in the interscapular region
      • it may also be felt in the epigastrium, left upper quadrant and occasionally praecordially
      • may last minutes to hours (not more than about six hours)
      • often occurs post-prandially
  • there can be associated nausea, vomiting and GI symptoms (belching, bloating, dyspepsia and flatulence)
  • uncomplicated cases usually resolve spontaneously or with analgesics (4)
    
    
• acute cholecystitis
  • present in around 36% of patients (3)
  • right upper quadrant pain which may radiate to the right shoulder
    • may be preceded by attacks of biliary colic
    • pain lasts for more than 12 hours
    • worse on movement and inspiration (4)
  • nausea, vomiting
  • fever
  • tenderness, guarding in the right upper quadrant and occasionally a palpable, tender mass
  • Murphys sign may be positive (4)
    
    
• other complications include:
  • obstructive jaundice
  • acute cholangitis
  • acute pancreatitis
  • gallstone ileus
  • mucocele of gallbladder
  • empyema of gallbladder
  • biliary peritonitis
  • gallbladder cancer.

Reference:

• (1) Sakorafas GH, Milingos D, Peros G. Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy. Dig Dis Sci. 2007;52(5):1313-25
• (2) Strasberg SM. Clinical practice. Acute calculous cholecystitis. N Engl J Med. 2008;358(26):2804-11
• (3) Sanders G, Kingsnorth AN. Gallstones. BMJ. 2007;335(7614):295-9.
• (4) Croton R. The basics -The management of gallstones. GPonline 2011