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CLINICAL REVIEW: Grant Sanders and Andrew N Kingsnorth Gallstones BMJ 2007; 335: 295-299 [Full text]

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Optimising management of emergency patients with symptomatic gall stones:

Amit Sinha   (13 August 2007)

What about ERCP in the management of gallstones?

Miles C Allison   (13 August 2007)

due recognition must be made of atypical presentations of choledocholithiasis

oscar,m jolobe   (14 August 2007)

Managing Gallstones

M.C. Bateson   (15 August 2007)

Features of pain in gallstone disease and Is gallstone ileus a misnomer?

Anton E Joseph   (15 August 2007)

MRCP and ERCP are cornerstones of gallstone management

Tom J W Lee, A Deepak Dwarakanath   (15 August 2007)

Imaging in acute cholecystitis and gall stone ileus

Anton E Joseph   (15 August 2007)

Imaging of Gallstones

David C Howlett   (21 August 2007)

Re: What about ERCP in the management of gallstones?

Grant Sanders   (22 August 2007)

Gallstone Ileus

Jit R Parmar   (23 August 2007)

Re: Imaging of Gallstones

NAZAR R DESSOUKI   (23 August 2007)

Gallstones: Why are doctors so poor at recognising biliary colic?

Heather I Lewis, Alastair McNair   (28 August 2007)

Managing gallstones. Don't forget ERCP.

Juliette K Loehry, Roger Frost (Radiologist)   (30 August 2007)

Follow-up after laparoscopic cholecystectomy

Rhys T Jones, Hazem Khout, David Bryant, Rory Farrell   (11 October 2009)

Optimising management of emergency patients with symptomatic gall stones: 13 August 2007
Amit Sinha, Consultant Surgeon Russells Hall Hospital, Dudley, West Midlands DY1 2HQ Send response to journal: Re: Optimising management of emergency patients with symptomatic gall stones:	The high conversion rates for emergency patients with symptomatic gall stones (20.3% in early cholecystectomy and 23.6% in delayed cholecystectomy) in the Cochrane review and an indication that specialist led service in Portsmouth for urgent cholecystectomy can reduce conversion rates (from laparoscopic to open cholecystectomy) to 12% suggests a need to focus our attention towards developing such a service throughout the NHS. In an audit carried out at our hospital we noted that approximately 50% of patients with symptomatic gall stones had their first contact with the hospital as an emergency. If this reflects the national figure then the management of a significant proportion of patients is sub-optimal in the present setup. If we consider that the average inpatient stay is 4 days longer after an open cholecystectomy then this also has obvious cost implications. Competing interests: None declared
What about ERCP in the management of gallstones? 13 August 2007
Miles C Allison, Consultant Gastroenterologist Royal Gwent Hospital, Newport NP15 1HG Send response to journal: Re: What about ERCP in the management of gallstones?	Sanders and Kingsnorth give a concise and evidence-based review of the surgical management of gallstones. Their only reference to endoscopic retrograde cholangiopancreatography (ERCP) is as a potential vehicle for introducing infection into the biliary tree. It is surprising that the authors devote an entire paragraph to the almost obsolete treatment of drug dissolution, yet fail to mention that ERCP and endoscopic sphincterotomy, with removal of common bile duct stones, is the first line treatment for acute cholangitis. Furthermore there is a large body of evidence for its role in the management of severe gallstone pancreatitis (1). As well as being the standard treatment for retained ductal stones, ERCP also plays an important role in the management of bile leaks post cholecystectomy (2). (1) Ayub K, Imada R, Slavin J Endoscopic retrograde cholangiopancreatography in gallstone-associated acute pancreatitis. Cochrane Database Syst Rev (England), 2004, (4) CD003630 (2) Kaffes AJ, Hourigan L, De Luca N, et al. Impact of endoscopic intervention in 100 patients with suspected postcholecystectomy bile leak. Gastrointest Endosc 2005; 61(2) 269-75 Competing interests: None declared
due recognition must be made of atypical presentations of choledocholithiasis 14 August 2007
oscar,m jolobe, retired geriatrician manchester medical society, c/o john rylands university library, oxford road, manchester m13 9pp Send response to journal: Re: due recognition must be made of atypical presentations of choledocholithiasis	Although the typical presentation of choledocholithiasis(ie calculi in the common bile duct) is one characterised by jaundice, ultrasonically detectable common bile duct(CBD) calculi, and biliary dilatation(1), such is the potential lethality of complications such as ascending cholangitis and acute pancreatitis that due recognition should also be made of atypical manifestations of this syndrome. These include:- (a)A presentation characterised by elevation in serum alkaline of hepatic origin(ie serum alkaline phosphatase typically associated with elevation in gamma glutamyl transpeptidase), in the absence of concurrent elevation in serum bilirubin(2), thereby potentially leading to a mistaken diagnosis of either an infiltrative or a space occupying lesion of the liver. (b) Instead of detecting CBD calculi in a patient with suspected choledocholithiasis(the sensitivity of ultrasound being of the order of 25% to 63% for detection of CBD calculi)(3), this modality may, in such patients, only detect calculi in the gallbladder, the sensitivity and specificity of this modality being of the order of 95% for the latter diagnosis(4). However, given the fact that the majority of CBD calculi are those which have migrated from the gallbladder, it can be inferred that the patient's clinical and biochemical stigmata are attributable to the latter mechanism even when ultrasound has failed to detect CBD calculi. (c)Instead of having concurrent cholelithiasis (ie calculi in the gallbladder) as an associated feature of choledocholithiasis, some patients have previous cholecystectomy as the feature which raises the index of suspicion for choledocholithiasis. In such cases the clinical and biochemical stigmata of choledocholithiasis are attributable, at least in part, to residual CBD calculi overlooked at the previous cholecystectomy. (d) The CBD may remain undilated even in the presence of choledocholithiasis(5), such a presentation being one which is especially challenging when ultrasound has failed to detect a CBD calculus. In this context the phenomenon of the undilated CBD is attributable to the poor correlation between intraductal pressure and biliary dilatation(6). References (1) Sanders G and Kingsnorth AN Gallstones British Medical Journal 2007:335:295-9 (2) Jones SN., Askew CM., Beynon CPJ., Crocker JR Isolated elevation of serum alkaline phosphatase in biliary disease in the elderly Postgraduate Medical Journal 1982:58:85-6 (3) Caddy GR and Tham TCK Symptoms, diagnosis and endoscopic management of common bile duct stones Best Practice & Research Clinical Gastroenterology 2006:20:1085-1101 (4)Shea JA., Berlin JA., Escarce JJ et al Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease Archives of Internal Medicine 1994:154:2573-81 (5)Welbourn CRB., Haworth JM., Leaper DJ., Thompson MH Prospective evaluation of ultrasonography and liver function tests for preoperative assessment of the bile duct British Journal of Surgery 1995:82:1371-3 (6) Staritz M., Poralla T., Klose K et al Is the bile ductb diameter a reliable parameter to diagnose extrahepatic cholestsis? Digestion 1986:35:120-4 Competing interests: None declared
Managing Gallstones 15 August 2007
M.C. Bateson, Consultant Physician/Gastroenterologist Bishop Auckland General Hospital, County Durham, DL14 6AD. Send response to journal: Re: Managing Gallstones	The splendid cover of BMJ 11th August 2007 raised expectations of being brought right up to date on cholelithiasis (page 295-9). It was a cruel disappointment. (1) Really important gallstones which must be dealt with occur in the bile ducts. Where is the discussion about diagnosis with MRI and CT, management with therapeutic ERCP, the place of open surgery, and discussion of optimal antibiotic therapy of ascending cholangitis in 2007? (2) Of course there are more cholecystectomies in the United States (population 290 million) than England (population 49 million). The interesting thing is that the rate per head of population is much greater in the American financially driven health care system compared with our public service ethos. The prevalence of gallstones is probably the same. (3) Andy Warhol died at 58 after apparently routine surgery. Surely death is the most serious complication of operative treatment! Gallbladder gallstones are no more likely to kill patients than the low mortality of their surgical treatment. This points up the apparent arbitrariness of the decision to operate in many cases. (4) Ursodeoxycholic acid is indeed useful to prevent gallstones in the weight loss period after bariatric surgery, and should be routinely considered. But it is also indicated for prophylaxis in octreotide and somatostatin therapy, which is probably the most potent iatrogenic cause of stones. Though UDCA has a very small place in therapy, two-thirds of lucent gallbladder stones less than 5 mm in diameter can be dissolved, and it cannot be dismissed entirely as a treatment. (5) One despairs to see the antique aphorism “F’s” trotted out in epidemiology. Forty-year-old females are not a prime risk group. They have fewer gallstones than men over 70 and age is a crucial factor in the UK. Though more than two pregnancies and the oestrogen in hormone replacement therapy can cause gallstones, the oral contraceptive pill is not lithogenic. There are important racial and international geographical variations in gallstone prevalence, and a strong association with haemolytic anaemia. This piece missed important targets and gave a less than comprehensive view of the subject. Competing interests: None declared
Features of pain in gallstone disease and Is gallstone ileus a misnomer? 15 August 2007
Anton E Joseph, Consultant Radiologist Mayday University Hospital, Croydon CR7 7YE Send response to journal: Re: Features of pain in gallstone disease and Is gallstone ileus a misnomer?	Many patients with gall stone disease present with non specific abdominal pain. We studied a group of patients attending a gastroenterology clinic with abdominal pain to identify the features that correlated best with gall stone disease. Biliary colic had the highest specificity (98%) but a low sensitivity (22%). Pain radiating to the back (most often to the inferior angle of the scapula) however had a sensitivity of 83% and a specificity of 74%. In comparison pain radiating to the back in peptic ulcer disease had a sensitivity of 25% and a specificity of 69%. Two hundred and eighty two consecutive patients attending a gastroenterology outpatient clinic were entered into the study. 41 patients (22%) had gallstones detected on ultrasound scans1. In the article bowel obstruction due to impaction of gall stone is labelled a misnomer. It may not be as inaccurate as the authors claim it is. Ileus is derived from the Greek word eileos, referring to intestinal colic and was associated with mechanical bowel obstruction. Eilo or ileus also seems to signify a coil or to roll up tight or twisted. Roman investigators used ileus to describe midgut volvulus, intussusception and incarcerated hernias because the symptoms of these conditions were similar. It appears that in the last 50 years the term ileus has come to mean non mechanical obstruction2. It would not therefore be entirely a misnomer to refer to the mechanical obstruction resulting from impaction of a gall stone as gall stone ileus. Therefore paying attention to the origin of the word ileus and also its modern usage it would be appropriate to refer to intestinal obstruction as ileus. With ileus resulting from mechanical obstruction when peristalsis is maintained as dynamic ileus and what is now referred to as paralytic ileus with absent peristalsis as adynamic ileus. Unrelieved dynamic ileus could however result in adynamic ileus or have a primary onset as in post operative states or peritonitis. References 1. Giovani G, Riadh PJ, Richard MK, Dharam PM, Lanzini A, Joseph AEA, Northfield TC. Value of different symptom complexes for clinical diagnosis of gallstones in out patients presenting with abdominal pain. Europ J Gastoenterol and Hepatology 1991;3:623-25 2. Ballantyne GH. The meaning of ileus. Its changing definition over three millennia. Am J Surg 1984;148:252-6 Competing interests: None declared
MRCP and ERCP are cornerstones of gallstone management 15 August 2007
Tom J W Lee, Specialist Registrar, Gastroenterology University Hospital of North Tees, Hardwick Road, Stockton upon Tees, Cleveland, TS19 8pe, A Deepak Dwarakanath Send response to journal: Re: MRCP and ERCP are cornerstones of gallstone management	It is a surprise to us that the clinical review of gallstones by Sanders and Kingsnorth (1) did not cover the role of MRCP (magnetic resonance cholangiopancreatography) and ERCP (endoscopisc retrograde cholangiopancreatography) in the management of gallstones, and yet found space to mention clinical rarities such as Bouvaret syndrome and gallstone ileus. We would also question the statement that liver function tests are a useful indicator of a stone in the bile duct. A raised bilirubin level is, of course, suggestive of common bile duct obstruction, but it would be erroneous to ‘guess’ the position of a gallstone based on blood results. As mentioned, ultrasonography is the key test to determine the presence or absence and position of gallstones. If ultrasonography shows a dilated common bile duct with gallstones present, an ERCP is usually indicated to clear the duct or establish drainage. If no common bile duct dilatation is seen, but gallstones are suspected, an MRCP is indicated to provide further diagnostic information on the position or absence of gallstones. The next step in management, be it ERCP, cholecystectomy or no intervention, can then be determined. 1. Sanders G, Kingsnorth A N. Gallstones. BMJ 2007;335:295-299 Competing interests: None declared
Imaging in acute cholecystitis and gall stone ileus 15 August 2007
Anton E Joseph, Consultant Radiologist Mayday University Hospital, Croydon CR7 7YE Send response to journal: Re: Imaging in acute cholecystitis and gall stone ileus	The review ‘focuses on the problems that gallstones cause and their optimal treatment.’ But aspects of diagnosis of gall bladder disease raised are inadequately covered. There are several reliable means of diagnosing of acute and chronic cholecystitis. The authors have stated the benefits of urgent or early cholecystectomy in comparison to delayed surgery in acute cholecystitis thus emphasising the need for accurate diagnosis. The ability to make a diagnosis of acute cholecystitis with ultrasound imaging has been known for a long time.1,2 The pathological process in acute cholecystitis results in the accumulation of oedema mainly in the subserosal layer giving rise to the characteristic ‘double walled’ appearance on ultrasound imaging. In my own experience this sign was noted in thirty five patients with a diagnosis of acute cholecystitis. Eighteen patients were operated within two weeks, the majority within eight to ten days. Eight patients were operated within ninety six hours of the onset of symptoms. Four gallbladders were obtained intact at surgery and scanned in a water bath with demonstration of the double wall sign. Histology confirmed acute cholecystitis in all patients2. Right hypochondrial pain, in combination with Murphy’s sign elicited by pressure with the ultrasound probe and the double wall sign is virtually diagnostic of acute cholecystitis. The double wall appearance by itself is not a specific sign of acute cholecystitis. Accumulation of oedema in the wall of the gallbladder also occurs in hypoalbumin states, heapatitis, congestive cardiac failure and portal hypertension. Physiologically contracted gall bladders often display the double wall sign. CT scans are also a very reliable way of diagnosing acute cholecystitis. Most of the findings with ultrasound could be demonstrated with CT scans apart from the probe pressure induced Murphy’s sign. If diagnosis of cholecystitis was inadequate then diagnosis of gall stone ileus is misleading with the claim that ‘gallstone ileus is often diagnosed intraoperatively, with almost a throw away comment ‘though supine abdominal radiography may show air in the biliary tree …..’It is not clear why the authors do not present the findings in the now well established imaging modalities. Clavien et.al. state that in twenty seven out of thirty seven patients (73%) the diagnosis was made preoperatively3. Lassandro et.al. retrospectively compared the value of plain abdominal film, abdominal sonography and abdominal CT in diagnosing gallstone ileus4. They had varying degrees of success with detecting features of gallstone ileus with the different imaging modalities. In their series CT revealed bowel dilatation in 93%, pneumobilia in 89% and ectopic stones in 81.5%, hence permitting diagnosis of gall stone ileus with a high success rate. In their series sonography was less useful. However it would be agreed by most experienced sonographers that a higher success rate could be achieved than quoted in their publication. With a relatively high mortality and morbidity associated with gall stone ileus, it is important to make an early preoperative diagnosis. Gall bladder cancer is detected not only as an incidental finding during cholecystectomy but also with ultrasound CT and MRI in symptomatic patients and also as an incidental finding. References 1. Marchall GJF, Casaer M, Baert AL, Goddeeris PG, Kerremans R, Fevery J. Gall bladder wall sonolucency in acute cholecystitis.Radiology1979;133:429 -33 2. Joseph AEA The gall bladder. Ultrasound in inflammatory disease In, Clinics in Diagnostic ultrasound, 1983 Vol11 Ed. Joseph AEA and Cosgrove DO. 3. Clavien PA, Richon J, Burgan S, Rohner A. Gall stone ileus. Br J Surgery 1990;77:737-42. 4. Lassandro F, Gagliardi N, Scuden M,Pinto A, Gatta G, Mazzeo R. Gallstone analysis of radiological findings in 27 patients. Eur J Radiol 2004;50:23-29 Competing interests: None declared
Imaging of Gallstones 21 August 2007
David C Howlett, Consultant Radiologist Eastbourne District General Hospital, Kings Drive, Eastbourne, East Sussex, BN21 2UD Send response to journal: Re: Imaging of Gallstones	Dear Editor I read with interest the recent review article concerning gallstones and their management [1] and would like to make some further comments in relation to imaging in gallstone disease. Abdominal radiography is are not routinely recommended for the assessment of suspected cholecystitis or gallstones – only approximately 10% of gallstones are radio-opaque. The classical plain film triad seen in gallstone ileus (small bowel dilatation, radio-dense gallstone and air in the biliary tree) is relatively unusual- due to cystic duct inflammation air often cannot pass into the biliary tree and gallstones are hard to identify within dilated fluid filled bowel loops. Ultrasound does represent the most accurate imaging modality for the identification of gallstones within the gallbladder and for changes in keeping with acute and chronic cholecystitis. No technique is completely accurate and occasionally stones will be missed sonographically, often when lying within the gallbladder neck. As the authors do recommend if there is persisting clinical concern following initial negative ultrasound scan an interval scan would be recommended. Ultrasound is able to delineate intrahepatic biliary tree dilatation and dilatation of the upper common bile duct but is not able to reliably delineate the distal common duct, due usually to overlying bowel gas. It is worth mentioning also the technique of magnetic resonance cholangiopancreatography (MRCP) which entails the rapid acquisition of T2 – weighted images through the biliary tree during a single breath hold. Bile appears of high signal on this sequence and this technique is highly accurate in delineating the biliary tree and is of particular use in patients with suspected choledocholithiasis. MRCP is non-invasive, enabling many patients to avoid ERCP and it is often used as a pre-operative screening tool to exclude intra-ductal calculi in patients undergoing laparoscopic cholecystotomy. Yours sincerely Dr David C Howlett MRCP FRCR Consultant Radiologist Email: David.Howlett@esht.nhs.uk [1] Sanders G, Kingsnorth AN. Gallstones. BMJ 2007; 335: 295-299 Competing interests: None declared
Re: What about ERCP in the management of gallstones? 22 August 2007
Grant Sanders, Locum Consultant Upper GI Surgeon Derriford Hospital, Plymouth Send response to journal: Re: Re: What about ERCP in the management of gallstones?	The authors agree entirely with the comments made about the usefulness of ERCP in the management of bile duct stones and bile leaks post cholecystectomy. However, the management of bile duct stones is an entire subject in itself. A review article such as ours is necessarily limited in size by the editorial board. Although the subject of bile duct stones was in the initial draft of the article, it was removed from the final draft. The target audience for this article is non-specialist hospital doctors, general practitioners, and candidates for postgraduate examinations. As such the authors felt it important to ensure that the place for drug dissolution therapy was clearly explained, as it is still a treatment used too frequently and inappropriately. Competing interests: None declared
Gallstone Ileus 23 August 2007
Jit R Parmar, Consultant General and Breast Midyorks Hospitals NHS Trust WF8 1PL Send response to journal: Re: Gallstone Ileus	I am referring to the Clinical Review article in BMJ2007;335:295-9, on page 296 Bouveret’s syndrome and gallstone ileus. Just to make a correction. We all refer to “ileus” loosely to describe “paralytic ileus”. There is another one called “mechanical ileus”. Both effectively produce obstruction. Ileus = the inability of the contents of the intestines to pass through them owing to physical obstruction, or muscular inadequacy, often accompanied by extreme pain and vomiting. Consequently gallstone ileus is not a misnomer, I am afraid. Competing interests: None declared
Re: Imaging of Gallstones 23 August 2007
NAZAR R DESSOUKI, CONSULTANT SURGEON ST BERNARDS HOSPITAL GIBRALTAR Send response to journal: Re: Re: Imaging of Gallstones	Imaging of the gallbladder for cholelithiasis and its complications has changed dramatically in recent decades along with expansion of interventional techniques related to the disease. Ultrasonography (US) is the method of choice for detection of gallstones. The characteristic US findings of gallstones are a highly reflective echo from the anterior surface of the gallstone, mobility of the gallstone on repositioning the patient, and marked posterior acoustic shadowing. Oral cholecystography remains an excellent method of gallstone detection, but its role has been limited due to the advantages of US. Most people with cholelithiasis will not experience symptoms or complications related to gallstones. When biliary colic does occur, it is typically caused by transient obstruction of the cystic duct by a stone. The primary imaging modality in suspected acute calculous cholecystitis is usually US or cholescintigraphy. Detection of gallstones alone does not permit a diagnosis of acute cholecystitis; however, secondary US findings provide more specific information. In detection of choledocholithiasis, endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography are superior to US. In certain clinical settings, interventional radiologic procedures have become an important alternative to surgery in the treatment of gallstones and their complications; techniques include percutaneous cholecystostomy and gallstone removal Competing interests: None declared
Gallstones: Why are doctors so poor at recognising biliary colic? 28 August 2007
Heather I Lewis, Specialist Registrar Gastroenterology Whipps Cross University Hospital, NE11 1NJ, Alastair McNair Send response to journal: Re: Gallstones: Why are doctors so poor at recognising biliary colic?	Dear sir/madam, The clinical review by Sanders and Kingsnorth provides a useful summary of the clinical spectrum of gallstone-related disease (1). While we agree with the comment that the ‘history is crucial in diagnosing biliary colic’ the table in the article summarising the symptoms caused by gallstones regrettably perpetuates the incorrect belief that this pain is ‘colicky’ in nature. The misnomer ‘biliary colic’ undoubtedly contributes to the difficulties inexperienced doctors have in diagnosing gallstone-related disease. There seems to be little consensus on the definition of biliary colic amongst doctors, but the commonly held belief that the pain is “colicky”, always in the right upper quadrant and associated with fatty meals, is not an accurate representation of what most patients experience. Colic is defined as a severe paroxysmal abdominal pain, waxing and waning in intensity, due to spasm, obstruction, or distension of one of the hollow viscera. Biliary colic however is not colicky; the intensity of the pain rises to a crescendo over a period of minutes to an hour and then persists as a constant severe, pain for between one and twenty four hours before resolving (2,3). The pain is often in the upper abdomen as stated in the article but is not uncommonly located in the lower retrosternal region causing confusion to the unwary casualty officer or general practitioner who may confuse the symptoms with severe reflux or cardiac pain, although radiation to the back is more common with biliary colic (2,3). Unlike ‘functional’ abdominal pain, biliary colic not infrequently wakes the patient from sleep at night and is frequently severe enough to cause vomiting (3). In between episodes, patients are usually completely free of pain or discomfort. We tested the ability of a group of junior doctors to diagnose biliary colic, using questionnaires that presented three evidence-based scenarios: one with typical features of biliary colic, one of dyspepsia and one of gastro-oesophageal reflux disease (GORD). They were given ten differential diagnoses and had to rank the top three most likely diagnoses for each scenario. They were then asked to give the first line investigation for each scenario from a list of ten investigations. A total of 47 questionnaires were completed. Only 21% of doctors correctly diagnosed biliary colic. Despite the classical history of biliary colic, this was mis-diagnosed as dyspepsia in 40% of cases. GORD was correctly identified by 69% of doctors, but only 36% correctly diagnosed dyspeptic symptoms with 14% incorrectly attributing dyspeptic symptoms to biliary colic. The difficulty in distinguishing dyspepsia from biliary colic may lead to unnecessary endoscopic examination and delayed diagnosis in patients whose management should be directed at their gallstones. Furthermore, ten to twenty percent of the population have cholelithiasis, but the majority (up to 75%) of these are asymptomatic at diagnosis. Long term follow up shows that only 10 to 25% of these will progress from asymptomatic to symptomatic disease (4). Up to 40% of the population are estimated to have dyspeptic symptoms at some time (5); if a significant proportion of these patients are incorrectly diagnosed as having biliary colic, on the basis of the presence of gallstones on ultrasound examination and a misunderstanding of the typical history of biliary colic, they may be submitted to unnecessary laparascopic cholecystectomy with no resolution of symptoms. Although based on small numbers, this study would suggest that the majority of junior doctors are unable to recognise biliary colic, even when presented with a patient giving a classical history. There is no reason to assume more experienced doctors would have performed much better. There is clearly a need to re-examine the way medical students and doctors are taught to differentiate different types of abdominal pain. Finding a new term to replace ‘biliary colic’ may go some way towards avoiding the current confusion. Dr Heather Lewis, Specialist Registrar in Gastroenterology Dr Alistair McNair, Consultant Gastroenterologist Queen Elizabeth Hospital Stadium Road London SE18 4QH REFERENCES 1. Sanders G, Kingsnorth AN. Gallstones BMJ 2007;335:295-9 2. Diehl AK, Sugarek NJ, Todd KH. Clinical Evaluation for Gallstone Disease: Usefulness of symptoms and signs in diagnosis. The American Journal of Medicine. 1990;89: 29-33 3. Romero Y, Thistle JL, Longstreth GF, Harmsen WS, Schleck CD, Zinsmeister AR, Pardi DS, Zein CO. A questionaire for the assessment of biliary symptoms. The American Journal of Gastroenterology. 2003; 98: 1042 -1051 4. Sakorafas GH, Milingos D, Peros G. Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparascopic cholecystectomy. Dig Dis Sci. 2007 May;52(5):1313-25 5. Malfertheiner P. Current concepts in dyspepsia: A world perspective. Eur J Gastroenterology Hepatol. 1999 Jun; 11 Suppl 1: s25-9 Competing interests: None declared
Managing gallstones. Don't forget ERCP. 30 August 2007
Juliette K Loehry, Consultant Gastroenterologist Salisbury District Hospital, SP2 8BJ, Roger Frost (Radiologist) Send response to journal: Re: Managing gallstones. Don't forget ERCP.	We enjoyed the article by Sanders and Kingsnorth on managing gallstones but were truly alarmed that no mention of the role of therapeutic ERCP (Endoscopic Cholangiopancreatography)in removing common bile duct stones was included in the treatment section. Like many interventional endoscopists, whether physicians, surgeons or radiologists, we devote considerable time during our working week to removing common duct stones during ERCP in non-anaesthetised sedated patients. Whilst we acknowledge the advances in surgical techniques enabling exploration of the duct on the operating table are now commonplace, the reality remains that this expertise is not universally available. A significant number of patients, particularly the elderly, presenting with common duct cholelithiasis related pathology will end up getting an ERCP, sphincterotomy and duct clearance regardless of their route of admission. Not only do these patients do very well in the long term, the majority escape cholecystectomy. The article also fails to mention those patients who present with biliary sepsis or obstruction as a result of residual (secondary) or de novo (primary) common duct stones after cholecystectomy. A number of these patients may present years after their original surgery, a fact that every vigilant GP should be made aware of and ideally trigger a direct referral for ERCP. Finally, please let us not forget the useful role of ERCP and temporary biliary stenting in sealing a post cholecystectomy bile leak, which will often save the patient a trip back to theatre. Although this complication is on the decline, we have little doubt that it will keep us ERCP'ists in business for many years to come! Competing interests: None declared
Follow-up after laparoscopic cholecystectomy 11 October 2009
Rhys T Jones, CT2, General Surgery Queen Elizabeth Hospital, Gateshead. NE9 6SX, Hazem Khout, David Bryant, Rory Farrell Send response to journal: Re: Follow-up after laparoscopic cholecystectomy	Surgical out-patient clinics operate under high demand, with further pressure added by 18 week targets and cancer referrals. Recent data suggests that routine surgery for benign pathology may be managed without out-patient follow-up and guidelines support this, but practices vary nationally 1,2. We reviewed a year’s experience of out-patient follow-up after laparoscopic cholecystectomy at a district general hospital, ending July 2007, and performed a cost-analysis. Of 196 patients under 9 consultants, 143 attended for planned review, 52 were discharged following surgery and one was transferred to the regional hepatobiliary unit following bile duct injury. None of those discharged directly following surgery were re- referred. Of the 143 clinic reviews, 122 patients were discharged without further investigation or intervention; three of these were subsequently re -referred. 21 patients had further investigation or management in clinic for complications, commonly nausea, pain, herniae or infection. Such problems could be managed effectively in primary care or referred back to clinic. During this period, 85% of follow-ups were therefore uneventful, at a cost of £13,420 to the trust. Practices do vary significantly between centres and telephone follow-up after day-case surgery is becoming more common. With some 42,000 elective laparoscopic cholecystectomies undertaken annually in England however, there may still be significant scope for improving the cost-effectiveness of this procedure. 1. Gurjar SV, Kulkarni D, Khawaja HT. Outpatient general surgical follow-up: Are we using this resource effectively? Int J Surg 2009;7:62- 65. 2. NHS Institute for Innovation and Improvement. Focus on: cholecystectomy-a guide for commissioners. 2006. Competing interests: None declared