Checked: 27-10-2017 by
vicky.ryan Next Review: 03-11-2017
Gallstones NS MOM
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
the assessment and management of both symptomatic and asymptomatic gallstones in adults
the assessment and management of conditions commonly associated with gallstones in adults, such as:
common bile duct stones (CBDS)
Out of scope:
the assessment and management of gallstones (and associated conditions) in children
the assessment and management of acute pancreatitis
gallstones are abnormal masses of a solid mixture of cholesterol crystals, mucin, calcium bilirubinate, and proteins
divided into the following categories, based upon their composition:
pure cholesterol stones
pure pigment stones
Incidence and prevalence:
gallstones are the most common cause of abdominal pain necessitating admission to hospital in the West − represent an important part of healthcare expenditure
prevalence of 12% in men and 24% in women in the UK 
prevalence of 10-15% in adults in Europe and the US 
incidence is very low in children and adolescents
50,000 cholecystectomy procedures took place in England in 2005/6 
pro-nucleating factors, such as:
impaired gallbladder mobility
elevated levels of hydrophobic biliary deoxycholate − eg due to presence of Gram positive anaerobic bacteria with 7α-dehydroxylation activity
eg due to infection or Crohn's disease
may predispose to gallstone formation by impairing entero-hepatic circulation and metabolism of bile acids
Major risk factors:
age − incidence of gallstones increases significantly over age 40 years 
female sex − 11% of women in their 40s suffer from gallstones 
pregnancy and parity − pregnancy related gallstones more than 1cm in size can disappear in about 30% women 
oestrogen replacement therapy
oral contraception use − usually elicit response soon after commencement
prolonged fasting or rapid weight loss, eg following bariatric surgery
Minor risk factors:
ethnicity − lower prevalence in Asians, Africans and African-Americans
metabolic disorders, such as:
type II diabetes mellitus
long-term total parenteral nutrition (TPN)
bile salt loss, eg due to ileal disease/resection
medications, such as:
Somatostatin analogues e.g. octreotide (suppresses gallbladder contraction)
dietary factors, including:
high fat content
low fibre content
high refined carbohydrates content
acute inflammatory disease of the gallbladder
mucocoele of gallbladder
common bile duct stones - CBDS:
have a different composition to primary stones
typically originate in the gallbladder and migrate
originate and develop in the biliary system
associated with biliary infection and stasis
very rare in the UK population
acute pancreatitis − secondary to CBDS
obstructive jaundice − secondary to CBDS or Mirrizi’s syndrome where large gallbladder stone compresses and obstructs the biliary tree
acute cholangitis is a morbid condition with acute inflammation and infection in the bile duct
secondary to CBDS − requires biliary obstruction and bile infection
gallstone ileus − secondary to cholecystoduodenal fistula
 Sanders G, Kingsnorth AN. Gallstones. BMJ 2007; 335: 295-9.
 Portincasa P, Moschetta A, Palasciano G. Cholesterol gallstone disease. Lancet 2006; 368: 230-9.
This care map was updated in line with the following guidelines:
 British Columbia Medical Association (BCMA). Guidelines and Protocols Advisory Committee. Treatment of gallstones in adults. Victoria, BC: BCMA; 2007.
 American College of Physicians (ACP). Guidelines for the treatment of gallstones. Ann Intern Med 1993; 119: 620-2.
 National Institute of Health (NIH). Gallstones and laparoscopic cholecystectomy. Consensus Statement 1992; 10: 1-26.
 Williams EJ, Green J, Beckingham IJ et al. Guidelines on the management of common bile duct stones (CBDS). Gut 2008; 57: 1004-21.
 American Society for Gastrointestinal Endoscopy (ASGE). The role of ERCP in disease of the biliary tree and the pancreas. ASGE: 2005.
 Kimura Y. Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007; 14: 15-26.
 Miura F. Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007; 14: 27-34.
 Hirota M. Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007; 14: 78-82.
 Tanaka A. Antimicrobial therapy for acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007; 14: 59-67.
 Yuichi Y. Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007; 14: 91-7.
 Toshio T. Techniques of biliary drainage for acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007; 14: 35-45.
 Wada K. Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007; 14: 52-8.
 Nagino M. Methods and timing of biliary drainage for acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007; 4: 68-77.
 The Royal College of Physicians (RCP), the Academy of Medical Royal Colleges (AMRC). A clinician’s guide to record standards – Part 1: Why standardise the structure and content of medical records? London: Digital and Health Information Policy Directorate; 2008.
 The Royal College of Physicians (RCP), the Academy of Medical Royal Colleges (AMRC). A clinician’s guide to record standards – Part 2: Standards for the structure and content of medical records and communications when patients are admitted to hospital. London: Digital and Health Information Policy Directorate; 2008.
 National Institute for Health and Clinical Excellence (NICE). Venous thromboembolism: reducing the risk. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. Clinical guideline 92. London: NICE; 2010.
 American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc 2010; 71: 1-9.
 National Institute for Health and Clinical Excellence (NICE). Single-incision laparoscopic cholecystectomy. London: NICE; 2010.
Local administrative information
Laparoscopic Cholecystectomy for Gallstones in Adults
Criteria Based Access Policy
Date Adopted: 22 December 2017
SYMPTOMATIC GALLSTONES ONLY
Policy - Criteria to Access Treatment – CRITERIA BASED ACCESS
Cholecystectomy is the surgical removal of the gall bladder.
Cholecystectomy will be funded for patients with symptomatic gallstones where there is documented evidence within the patient records of an episode resulting in pain / nausea linked with any of the following:
1. Calculus of gallbladder with acute cholecystitis
2. Calculus of gallbladder with other cholecystitis
3. Calculus of bile duct with cholangitis ( infection of the bile duct)
4. Calculus of bile duct with cholecystitis
5. Calculus of gallbladder with impacted Gallstone or Recurrent Biliary Colic
6. Emergency presentation of acalculous cholecystitis where surgery is appropriate
7. After pancreatitis - if appropriate
Patients with suspected gallbladder cancer should be referred via the 2 week wait pathway.
Patients with severe complications should be referred immediately, without delay.
ASYMPTOMATIC GALLSTONES ONLY
Policy - Criteria to Access Treatment – CRITERIA BASED ACCESS
Cholecystectomy is the surgical removal of the gall bladder.
Prophylactic cholecystectomy is not indicated in most patients with asymptomatic gallstones. The removal of the gallbladder for asymptomatic / silent gallstones will only be considered if one or more of the following criteria are met. This must be fully documented in the patient’s records.
1. Where there is clear evidence of patients being at risk of Gallbladder Carcinoma.
2. With family history of carcinoma of the gallbladder
3. With single solitary gallstone greater than 3 cm in size
4. With Porcelain gallbladder
5. Gallbladder polyps greater than 1 cm size
6. With Sickle Cell disease and other chronic haemolytic diseases
7. Immunocompromised patients and transplant recipient patients
8. The Patient is undergoing abdominal surgery for other indications(e.g. cirrhosis of the liver or other Gastro-intestinal indications)
9. The Patient has increased risk of developing complication (with non-functioning gall bladder, gallstones > 2cm size, choledocholithiasis and obstructive jaundice).
10. The Patient has complex diabetes (uncontrolled glycaemia, diabetics with co-morbidities such as heart failure, renal failure, and/ or circulatory problems).
persistent right upper quadrant (RUQ)/epigastric pain with marked tenderness
a positive Murphy’s sign:
indicative of inflammation associated with acute cholecystitis
elicited by asking the patient to inspire deeply with the examining hand immediately below the right costal margin in the mid-clavicular line
an inflamed gallbladder is indicated by patient experiencing pain and catching their breath as the gallbladder descends
low-grade pyrexia (high-grade pyrexia may indicate cholangitis)
delayed presentation with systematic sepsis from gallbladder abscess (empyema) and rarely perforation
complications of common bile duct (CBD) stones:
gallstones associated with painful jaundice indicates obstruction of the common bile duct by a gallstone migrating from the gallbladder
rarely, a large stone resident in the gallbladder may compress the biliary tree to present in a similar fashion (Mirrizi's syndrome)
painless jaundice is rarely attributable to gallstone pathology
patients may complain of pale stool and/or dark urine
Charcot’s triad of jaundice, RUQ pain, and fever (typically with rigors) is diagnostic
indicates super-added infection of the obstructed biliary system
central epigastric pain radiating through to the back
difficult diagnosis to make in primary care, but should be considered in all unwell patients with a history of gallstones
Blood work :
blood tests are not usually indicated in the diagnosis of gallstones
the majority of patients with episodic biliary colic would demonstrate normal blood results
elevated inflammatory markers would make the diagnosis of uncomplicated biliary colic unlikely, and should prompt further investigation
however, mildly elevated liver function tests can be associated with gallstones if testing takes place during an episode of acute pain − these should be rechecked at an interval to ensure resolution and exclude other causes
abdominal ultrasound is the recommended first-line investigation 
sensitivity varies and is operator dependent, but is generally good (79-99%) 
ultrasound findings of a thickened gallbladder wall and pericholecystic fluid suggest the presence of acute cholecystitis 
radionuclide scanning is not useful for the diagnosis of gallstone disease − it has a high sensitivty for the detection of acute cholecystitis but is rarely employed 
 Keus F, de Jong JA, Gooszen HG, Van LaarhovenCJ. Laparoscopic versus small-incision cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 2006; CD006229.
Alternative causes of epigastric/right upper quadrant (RUQ) pain include:
gastritis/peptic ulcer disease 
myocardial ischaemia/infarction (MI) 
inflammatory or neoplastic disease of the colon 
oesophageal spasm 
irritable bowel syndrome 
 Beckingham IJ. ABC of diseases of liver, pancreas, and biliary system. Gallstone disease. BMJ 2001; 322: 91-4.
Acute episode management :
management of an acute episode of uncomplicated biliary pain or colic should be directed at controlling symptoms such as pain and nausea
most episodes can be managed at home
Antiemetic choice will depend on co-existing patient specific factors