MKSAP Quiz: Management of gallstone disease
This month's quiz asks readers to determine the most appropriate course of management for a 65-year-old man with multiple gallstones found on ultrasonography screening for abdominal aortic aneurysm.
A 65-year-old man undergoes screening with ultrasonography for abdominal aortic aneurysm. He has no symptoms, his medical history is unremarkable, and he takes no medication.
Vital signs and other findings of the physical examination are normal.
On the abdominal ultrasound, the abdominal aorta appears normal. Multiple gallstones smaller than 1 cm in size are seen in the gallbladder. The liver has normal echogenicity, and there are no dilated bile ducts. No abnormalities are seen in the gallbladder wall.
Which of the following is the most appropriate management of this patient's gallstone disease?
A. Cholecystectomy
B. Endoscopic retrograde cholangiopancreatography
C. Repeat ultrasonography in 6 months
D. Clinical observation
MKSAP Answer and Critique
The correct answer is D. Clinical observation. This content is available to MKSAP 18 subscribers as Question 71 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
This patient's asymptomatic gallstone disease requires no further intervention at this time but should be managed as symptoms arise. Gallstone disease is a common finding in up to 15% of patients in Western countries. Gallstones that are found incidentally during abdominal imaging performed for another reason do not usually require intervention. Stones that produce symptoms typical of biliary colic or cause symptoms due to passage of the stone into the common bile duct require intervention. This patient has no symptoms potentially attributable to gallstones, and the ultrasonographic findings do not suggest any complications of gallstones. Because there are no complications, no intervention is necessary at this time and clinical observation is the appropriate management.
Eighty percent of patients with asymptomatic gallstones remain asymptomatic over a 15-year period, and most serious complications of gallstone disease are preceded by an episode of biliary colic; therefore, cholecystectomy is not generally advised in asymptomatic patients. Indications for cholecystectomy include symptomatic disease such as biliary colic or cholecystitis. Prophylactic cholecystectomy is recommended for patients with an anomalous pancreaticobiliary duct junction, gallbladder polyps 1 cm or larger, gallbladder polyp(s) with concomitant gallstones, or polyps of any size in the setting of primary sclerosing cholangitis. Prophylactic cholecystectomy can also be considered in patients with a porcelain gallbladder or with gallstones larger than 3 cm. These patients are at increased risk for gallbladder cancer. In this patient with small, asymptomatic gallstones, there is no indication for surgical intervention.
Referral for endoscopic retrograde cholangiopancreatography (ERCP) is not warranted in this setting because the patient is asymptomatic. Patients with gallstones in the common bile duct or patients who are not candidates for cholecystectomy may benefit from ERCP with sphincterotomy to reduce the risk for recurrent bouts of cholangitis.
Serial abdominal imaging, such as ultrasonography, to monitor asymptomatic gallstones is not warranted. Patients with gallbladder polyps may benefit from monitoring with serial gallbladder ultrasound because gallbladder polyps are a risk factor for gallbladder cancer. Diagnosis at a late stage contributes to the poor prognosis of gallbladder cancer.
Key Point
- Incidentally found gallstones with no associated symptoms and no complications require no further intervention.