Painless Choledocholithiasis in African American and Hispanic Patients

Abstract

Background: Typical symptoms of choledocholithiasis include colicky right upper quadrant abdominal pain, nausea, vomiting, fever and jaundice. However elderly patients with choledocholithiasis may present with atypical manifestations and without biliary colic. Objective: To determine the frequency of painless presentation of choledocholithiasis by age, sex and race/ethnicity. Methods: Retrospective review of medical records of 527 patients aged 23 to 97 years over 10-year period with a definitive diagnosis of choledocholithiasis. The diagnosis was suspected by abnormal liver chemistry, abdominal ultrasound (US) and/or computerized tomographic (CT) scan of abdomen, and was confirmed by one or more of the following: endoscopic retrograde cholangiopancreatography, surgery, intraoperative cholangiogram. Presence or absence of pain at the time of admission and findings of US and CT were recorded. The patients were stratified according to age into three groups: 23-65 years (Group I): 216 patients, 66-75 years (Group II): 199 patients, 76-97 years (Group III): 112 patients. Data were analyzed by age, sex and race/ethnicity. Results: Of 527 patients 124 had painless presentation (24%). Number of patients presenting without abdominal pain differed significantly by age (Group I = 16%, Group II = 26% and Group III = 33%, p = 0.001). The odds of having painless presentation for subjects in age group III was 2.5 times that of those in age group I (Odds Ratio = 2.5, 95% Confidence Interval = 1.4-4.5). Painless presentation did not differ by sex (male = 23%, female = 24%, p = 0.8), or race/ethnicity (African American = 24%, Hispanics = 23%, p = 0.8). Conclusions: A significant number of patients may present with painless choledocholithiasis. The presentation of painless choledocholithiasis increases with aging. Clinicians should have a high index of suspicion for choledocholithiasis, and low threshold for diagnostic testing in the patients presenting with abnormal liver tests even in absence of abdominal pain.