Gallstones
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39267.452257.AD (Published 09 August 2007) Cite this as: BMJ 2007;335:295
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests