Silent Gallstones Research Articles

Cracking the silent gallstone code: Wait or operate?

The widespread availability of abdominal ultrasound has revealed the common occurrence of asymptomatic gallstones. While the treatment for symptomatic gallstones is clear, the benefits of minimally invasive laparoscopic cholecystectomy have sparked debate about the best approach to managing silent gallstones. The potential for asymptomatic gallstones to become symptomatic or lead to complications complicates the decision-making process regarding surgical intervention, as it's uncertain when or which patients might develop complications. Consequently, risk stratification appears to play a critical role in guiding decisions about silent gallstones. However, there is no definitive evidence to direct management, and a consensus-based on high-quality evidence is yet to be established.

Acute pancreatitis: It can be the first sign of silent gallstones.

The management of asymptomatic cholelithiasis is controversial. Silent gallstones are generally assumed to cause complications after at least one episode of biliary colic. The ratio of those silent stones that had initially caused, -or were diagnosed as the etiological agent of- acute pancreatitis has not been reported in the literature yet. Our study was designed to investigate the ratio of asymptomatic cholelithiasis in acute biliary pancreatitis cases. One hundred and seventy-one patients of 305 cases, who were followed up with the diagnosis of acute biliary pancreatitis, were identified retrospectively. Demographic specifications, laboratory findings and clinical progressions of the patients were inspected. Clinical histories were detailed by phone calls. Gallstones were radiologically detected in 85 out of 171 cases. Those patients were divided as symptomatic and asymptomatic. Clinical findings and follow-ups were evaluated by "Chi-square" test. In the study group, 80% of the patients were asymptomatic (n= 68) and 16.47% of the patients (n= 14) had complicated pancreatitis. Regarding the severity of the clinical course, being symptomatic or not was not identified as a significant factor (p= 0.108). In regard of creating symptoms, the size of the stone was not significant (p= 0.561) and obtained no prediction about the clinical severity of the pancreatitis (p= 0.728). Asymptomatic cholelithiasis patients had a major percentage in acute biliary pancreatitis cases. The "wait and see" approach should be re-evaluated for silent gallstones in prospective trials.

Cholecystectomy for Gallstone: Types and Findings

Gall stone disease remains a common and significant cause of suffering in most parts of the world. Gallstones are the most common biliary pathology. A descriptive study covered 80 patients underwent surgical treatment for gallstone diseases. Ultrasound study and plain abdominal X-ray were done to confirm the presence of gallstone. More than half of the sample 58.8% were in the oldest age group 50-69 year. Female were 68(85%) and the remaining 12(15%) patients were male. Most of patients 60(75.0%) operated upon by open cholecystectomy, laparoscope used in 18(22.5%). The main finding on exploring the abdomen was inflammatory adhesion in 54(67.5%) of the patients, thick wall gallbladder came next in 12 (15%) patients. Many complications and clinical findings associated with gallstone, some of them are serious other are even fatal. That is why cholecystectomy is highly indicated even for silent gallstone. Keywords: Gallstone, Jaundice, Cholecystitis, Surgery, Laparoscopy DOI: 10.7176/JHMN/71-09 Publication date: February 29 th 2020

Acute Cholecystitis as a Complication after Colonoscopy: A Case Report and Literature Review.

Acute cholecystitis after colonoscopy is a rare event, with less than 10 cases described in the literature. We report the case of a male patient with silent gallstones who underwent colonoscopy for follow-up of his Crohn’s disease. The colonoscopy revealed erosions in the terminal ileum, from which biopsies were taken. A sessile polyp 4 mm in diameter at the recto-sigmoid junction was also removed. Less than 24 h after the colonoscopy, the patient complained of upper right quadrant pain, nausea and vomiting. Based on the clinical findings, laboratory data and ultrasonography, we diagnosed acute cholecystitis and excluded any complication after the colonoscopy. Laparoscopic cholecystectomy was performed and the patient was discharged.LEARNING POINTSCholecystitis following colonoscopy can be a rare complication or a coincidence.Rarely, manoeuvres during colonoscopy may dislodge small gallstones which then obstruct the bile duct causing acute cholecystitis.Imaging and the clinical picture help to differentiate bowel perforation, a fairly common early event after colonoscopy, from other complications.

Histopathological changes of gallbladder mucosa in silent gallstone diseases

Histopathological changes of gallbladder mucosa in silent gallstone diseases

Need for Prophylactic Cholecystectomy in Silent Gall Stones in North India

One of the criteria for recommending cholecystectomy for silent gall stones, is gall stones in regions with high incidence of gall bladder cancer. Both gall stones and gall bladder cancer are common in North India. All tertiary care centres in India report high rates of gall bladder cancer (GBC) incidence and poor treatment outcomes in the majority of cases due to advanced stage of presentation. Csendes of Chile has reported very high incidence of gallbladder cancer in Chile and Bolivia and advocated prophylactic cholecystectomy in asymptomatic patients. Incidence rate of gall bladder cancer in Indian males is equal to that of Chile, whereas in females, the rates are almost double the rates of Chile. Indians have also been found to have high concentrations of heavy metals in gall bladder wall, and antibodies to tumor suppressor genes. In India, gall bladder cancer is the commonest GI cancer in women and fourth commonest cancer overall in the female population. In view of the epidemiology and clinical scenario of gall bladder cancer and proven safety of laparoscopic cholecystectomy, there is a need to act before it is too late in the current rates of gall bladder cancer. This study looks at the evidence correlating gall stones and gall bladder cancer, in relation to India. There is pressing evidence today to justify a strategy of prophylactic cholecystectomy in silent gall stones in North India. Data for this study was selected through an internet based search for literature concerning gall stones and gall bladder cancer in India, and for prophylactic cholecystectomy.

Gallbladder Kinetics: Correlation between Gall Bladder Emptying in Patients With and Without Cholelithiasis by Ultrasonography

Background: Gallstone disease or cholelithiasis, is one of the most common surgical problems worldwide. The assessment of gallbladder kinetics in patients with cholelithiasis as well as in patients with high risk for cholelithiasis could play a significant role in better management and is recommended as a routine workup of biliary system in these patients.Objectives: This study was carried out to establish the relationship between impaired gall bladder emptying and gall bladder stones. It also aimed at finding out correlation between chosen risk factors. Materials and Methods: Eighty six subjects with cholelithiasis and 35 controls (without cholelithiasis) were studied. Pre-prandial gall bladder volume was measured after 6 hours of fasting, gallbladder emptying was stimulated by fatty meals of 610 and 740Kcal and post-prandial gallbladder volume was measured after a period of two hours with ultrasound. The difference of pre-prandial and postprandial gall bladder volume was calculated. Results: Gallbladder emptying was significantly more (p < 0.001) in the control group than in the group of subjects with cholelithiasis. In the case group the mean difference of volume was 9.2±7.1 cc. While in control group the mean difference of volume was 17.6±14.3. The prevalence of cholelithiasis was significantly high in females between 26- 35 years of age group and in patients with nonalcoholic fatty liver disease and in patients who had first degree relative with gall stone. Incidence of silent gall stone was also statistically significant. Conclusion: Impaired gallbladder emptying was found to be strongly associated with gall stones. NJR I VOL 2 I ISSUE 1 13-17 Jan-June, 2012 DOI: http://dx.doi.org/10.3126/njr.v2i1.6973

Lithiase biliaire du nourrisson, de l’enfant et de l’adolescent

The prevalence of cholelithiasis is estimated within 0.13% and 2% of children under 19 years of age. Pigment stones are the commonest type of gallstones in children, without recognizable predisposing factors in infants or secondary to a predisposing disease such as chronic hemolysis and ileal disease in children. In adolescents, idiopathic cholesterol gallstones accounts for the majority, such as in adults. Gallbladder stones are found in 80 to 90% of cases and common bile duct stones in 10 to 20% of cases. When common bile duct stones are found, a choledocal cyst with anomalous pancreatobiliary duct junction needs to be excluded. Magnetic resonance cholangiopancreatography should be performed in first line. Cholecystectomy is not indicated for silent gallstones, except in children with a predisposing disease such as chronic hemolysis. Treatment of common bile duct stones includes interventional radiologic, endoscopic or surgical procedures. Stone extraction may be performed at endoscopic retrograde cholangiopancreatography with or without sphincterotomy, combined with laparoscopic cholecystectomy. In children without a predisposing disease or no residual gallstones indicating a cholescystectomy, conservative management (percutaneous cholangiography with biliary drainage) may be proposed in specialised centers, especially for infants. A hepaticojejunostomy is indicated in cases of choledocal cyst with anomalous pancreatobiliary duct junctions.

A 24-year controlled follow-up of patients with silent gallstones showed no long-term risk of symptoms or adverse events leading to cholecystectomy

Background. The fate of asymptomatic gallstones has not been investigated in many studies with a long-term follow-up. We wanted to examine the subsequent rate of cholecystectomy and gallstone-related symptoms in a population examined in 1983. Methods. Among the persons examined in 1983, unknown (perceived as silent) gallstones were discovered in 20.1% (285/1417) persons. Owing to technical reasons, only 89.9% (1274 persons) of the original study population was retrieved for the present study. Of these, 19.2% (245 persons) had gallstones in 1983 [135 women (55.1%) and 110 men (44.9%), mean age in 1983: 49.9 and 51.3 years, respectively]. Results. Of the 154 still living persons with gallstones from 1983, 134 were traced for follow-up. Of these, 89 underwent a clinical examination and 45 answered a mail or telephone questionnaire. Ultrasonography revealed gallstones in 28.1% (25/89) and 6.7% (9/134) had had the gallbladder removed. 5.5% (5/91) of the deceased patients had had a cholecystectomy. Overall cholecystectomy rate was 6.2%. No link could be shown between the number and the size of gallstones in 1983 and the ultrasonographic demonstration of gallstones in 2007. 43.8% had abdominal pain, and 29.2% had functional abdominal complaints. Conclusions. Unexpectedly, only a minority of persons examined with ultrasonography had present day gallstones without any obvious explanation for this low figure. The rate of cholecystectomy was low in a conservative setting and no adverse events could be ascertained from such a policy.

The role of laparoscopic cholecystectomy in alleviating gastrointestinal symptoms

Laparoscopic cholecystectomy is the standard treatment for symptomatic gall stone disease. This study is aimed at assessing the effect of the operation on patients' symptoms. 175 unselected consecutive patients admitted for laparoscopic cholecystectomy between June 2007 and June 2008 were recruited into the study. A standard questionnaire examined pain and other dyspeptic symptoms. Histories of psychiatric disturbances and gastroscopy were also evaluated. Bloating, glubus sensation and regurgitation were not cured by laparoscopic cholecystectomy. The cure rates for vomiting and non typical pain were in excess of 70%. Our study confirms that some symptoms are not alleviated by the operation. Furthermore, surgeons should be aware that the sub-group of patients whose preoperative symptoms include bloating, regurgitation and glubus sensation and who have required psychotrophic drugs may in fact have 'silent gall stones' and irritable bowel syndrome. Such patients are unlikely to benefit from laparoscopic cholecystectomy. Key words: Laparoscopic cholecystectomy, bloating, glubus sensation, regurgitation, gastroscopy.

Natural history of gallstone; an important and old issue, but still debatable

Natural history of gallstone; an important and old issue, but still debatable

Risk Factors, Complications, and Outcomes of Gallstones in Children: A Single‐center Review

The increasing use of sonography has resulted in an increase in the proportion of children with gallstones who are asymptomatic at the time of diagnosis. In adults, the literature supports expectant management of clinically silent gallstones. The evidence for this management approach in children is limited to a number of small series. Our objective was to review the risk factors, complications, and outcomes of gallstones at our institution, particularly in those patients who are asymptomatic at the time of initial diagnosis. We reviewed 382 cases of gallstones in children. These patients were diagnosed with sonography. Data on age at diagnosis, presentation, sonographic findings, risk factors, complications, surgery, and follow-up were collected. A chi2 test was used to compare the complication rates between symptomatic and asymptomatic groups. Descriptive statistics were used to analyze the sample. At diagnosis, 50.5% of children were asymptomatic; these patients were diagnosed at a mean age of 8.23 years. Compared with symptomatic patients, they were less likely to have a hemolytic anemia but more likely to have other risk factors, including cardiac surgery, leukemia and lymphoma, short bowel syndrome, or exposure to total parenteral nutrition or cephalosporins. These patients had a lower rate of complications than the symptomatic patients (4.6% vs 28.2% of symptomatic, P < 0.0001) and only 3.1% developed symptoms that necessitated surgery (vs 59.0% of symptomatic). Of the 58 (15.1%) diagnosed in infancy, 47 (81.0%) were asymptomatic. The infant group also had low rates of complications (8.6%) and cholecystectomy (1.7%). In cases with sonographic follow-up, resolution of gallstones was demonstrated in 16.5% of asymptomatic patients and in 34.1% of infants. The data suggest that clinically silent gallstones in children and infants are associated with low rates of complications and can be managed conservatively, unless complications occur. Patients with sickle cell disease, spherocytosis, and elliptocytosis had high complication rates and required surgery more often.

Gallbladder Carcinoma, Improving Diagnosis and Outcome

Objective: The purpose of this study is to determine the pattern of presentation of carcinoma of the gall bladder in Saudi patients and to assess the accuracy of diagnostic modalities, namely ultrasound and computerized scan, in detecting the disease, together with an extensive literature review to establish suspicious criteria helping in early diagnosis of this lethal disease.Methods: This is a retrospective study of patients diagnosed to have gallbladder carcinoma at King Fahad Medical City, Riyadh, K.S.A. in the period from January 2007 to January 2010.Results: Six patients were included, 5 females and one male (age range between 58 and 87 years, with a mean age of 73 years. The main presenting symptoms were abdominal pain (83.3%), nausea and vomiting (50%). Two patients were found to be jaundiced (33.3%), an abdominal mass was felt in one patient (16.6 %) and weight loss was seen in 4 patients (66.7%). Liver function test showed abnormal liver enzymes in 3 patients (50%), elevated bilirubin in two patients (33.3%), elevated alkaline phosphatase in 4 patients (66.7%) and low albumin in all patients (100%). Low hemoglobin was observed in 2 patients (33.3%). abdominal ultrasound was suspicious for gallbladder carcinoma in two patients (33.3 %), gallstones and chronic cholecystitis were found in the remaining 4 patients. CT scan was performed in 4 patients and it was suspicious of gallbladder cancer in all of them (100%). It detected evidence of liver invasion and hepatic metastasis in one of the 2 operated cases; however, it failed to detect liver invasion in one of the operated patients who subsequently was proved to have liver invasion on histological examination of the liver resection specimen. Histology confirmed diagnosis of adenocarcinoma in all patients with variable degree of differentiation.Conclusions:The poor prognosis of gallbladder cancer is related to its dissemination capacity and usually late diagnosis due to its non-specific clinical presentation. The traditional routine approach of investigation and management of patients with gallbladder stones which depends mainly on ultrasound as diagnostic modality may delay the diagnosis and waste the chance of early detection of gallbladder carcinoma when curative resection is achievable. We recommend a high index of suspicion in patients with gallstones in presence of a combination of female sex, old age, silent gallstones presenting at late age, and thickened wall of the gallbladder on ultrasonic examination. We also recommend adding more sensitive investigation like CT scan, EUS, and ultrasound-guided aspiration cytology/biopsy to the protocol of investigation of these patients.

Asymptomatic Gallstones: What We Should Do?

Cholelithiasis is common (10-25%) in the general population, with the majority (70-80%) being asymptomatic at the time of diagnosis, and only few (10-20%) produce symptoms or complications in life time. Cholecystectomy, either open or laparoscopic, is straight forward for symptomatic gallstones, unlike the controversies in asymptomatic or silent gallstones. Stones with true biliary ‘colic’ (and not the vague dyspeptic symptoms) are considered symptomatic. Patients on long-term parental nutrition and liver cirrhosis have high prevalence of asymptomatic stone formation. Transient gallbladder sludge or stone formation is common in children treated with high doses of ceftriaxone or in pregnancy. Diabetic patients with asymptomatic stones are no longer considered at being at high risk of developing symptoms or complications. In case of an asymptomatic gallstone together with a common bile duct stone, endoscopic treatment of the ductal stone is sufficient, leaving the gallbladder in situ. Most of the transplant patients with asymptomatic gallstones can safely undergo cholecystectomy when their asymptomatic stone turns symptomatic. On the other hand, good risk patients undergoing abdominal surgery may undergo concomitant cholecystectomy for asymptomatic gallstones. Certain geographical areas with high incidence of cholelithiasis and gallbladder malignancy may have a relaxed policy for cholecystectomy. Except in high-risk groups, most of the studies favor a ‘wait and watch’ policy for asymptomatic gallstones. Aim of this comprehensive review is to analyze the available evidence to help both clinician and patients to make a decision in case of asymptomatic or silent gallstones.

Asymptomatic Cholelithiasis: Is Cholecystectomy Really Needed? A Critical Reappraisal 15 Years After the Introduction of Laparoscopic Cholecystectomy

Asymptomatic cholelithiasis is increasingly diagnosed today, mainly as a result of the widespread use of abdominal ultrasonography for the evaluation of patients for unrelated or vague abdominal complaints. About 10-20% of people in most western countries have gallstones, and among them 50-70% are asymptomatic at the time of diagnosis. Asymptomatic gallstone disease has a benign natural course; the progression of asymptomatic to symptomatic disease is relatively low, ranging from 10-25%. The majority of patients rarely develop gallstone-related complications without first having at least one episode of biliary pain ("colic"). In the prelaparoscopy era, (open) cholecystectomy was generally performed for symptomatic disease. The minimally invasive laparoscopic cholecystectomy refueled the discussion about the optimal management of asymptomatic cholelithiasis. Despite some controversy, most authors agree that the vast majority of subjects should be managed by observation alone (expectant management). Selective cholecystectomy is indicated in defined subgroups of subjects, with an increased risk for the development of gallstone-related symptoms and complications. Concomitant cholecystectomy is a reasonable option for good-risk patients with asymptomatic cholelithiasis undergoing abdominal surgery for unrelated conditions. Routine cholecystectomy for all subjects with silent gallstones is a too aggressive management option, not indicated for most subjects with asymptomatic cholelithiasis. An in-depth knowledge of the natural history of gallstone disease is required to select the optimal management option for the individual subject with silent gallstones. Management options should be extensively discussed with the patient; he or she should be actively involved in the process of therapeutic decision making.

Cholecystectomy versus no cholecystectomy in patients with silent gallstones.

Cholecystectomy is currently advised only for patients with symptomatic gallstones. However, about 4% of patients with asymptomatic gallstones develop symptoms including cholecystitis, obstructive jaundice, pancreatitis, and gallbladder cancer. To assess the benefits and harms of surgical removal of the gallbladder for patients with asymptomatic gallstones. We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until 2006 for identifying the randomised trials using The Cochrane Hepato-Biliary Group search strategy. Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing cholecystectomy and no cholecystectomy were considered for the review. We were unable to identify any randomised clinical trials comparing cholecystectomy versus no cholecystectomy. We were unable to identify any randomised clinical trial comparing cholecystectomy versus no cholecystectomy. There are no randomised trials comparing cholecystectomy versus no cholecystectomy in patients with silent gallstones. Further evaluation of observational studies, which measure outcomes such as obstructive jaundice, gallstone-associated pancreatitis, and/or gall-bladder cancer for sufficient duration of follow-up is necessary before randomised trials are designed in order to evaluate whether cholecystectomy or no cholecystectomy is better for asymptomatic gallstones.

Contribution of silent gallstones in gallbladder cancer

Silent (asymptomatic) gallstones are detected frequently with the widespread use of abdominal ultrasonography. The presence of gallstones is found strongly associated with gallbladder carcinoma. Studies on the natural history and most decision analysis studies do not favor prophylactic cholecystectomy for patients with silent gallstones. Gallbladder carcinoma is known to be highly aggressive and lethal disease with a poor outcome. It is rarely diagnosed early and only 10-30% patients are offered radical surgery on presentation. This has lead to a dilemma leading most surgeons to opt for an expectant management of silent gallstones. It thus raises the important question of the implications of leaving asymptomatic gallstones untouched. In this paper the author has reviewed the current understanding on silent gallstones and gallbladder carcinoma.

Asymptomatic gallstones

The increasing detection of asymptomatic gallstones leads to difficult decisions for the surgeon and patient about whether the stones should be managed expectantly or surgically. This review examines the evidence currently available upon which such decisions must be based. Gallstones may present as biliary pain, acute cholecystitis, biliary obstruction or pancreatitis, but it is not clear who will develop symptoms and what are the commonest initial symptoms. Studies of the natural history of silent gallstones suggest that a large majority of patients with such stones will remain asymptomatic. However, diabetics are at increased risk, as are patients whose stones are detected initially at laparotomy. Incidental cholecystectomy is usually safe, and preoperative detection by ultrasonic screening is an advantage in planning the operation. Prophylactic cholecystectomy is not indicated to prevent gallbladder carcinoma (except in cases of porcelain gallbladder) and there is conflicting evidence about whether cholecystectomy predisposes to colorectal carcinoma.

The standard of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy today is the standard operation for all gall stone disease. Nevertheless, a number of questions are still being discussed: What are the optimal steps? Or, more important, is the laparoscopic technique really superior to the open procedure according to the criteria of evidence-based medicine? How should we proceed in case of an occult choledocholithiasis? Is intraoperative cholangiography mandatory, and does the concept for the treatment of silent gall stones need to be revised in the era of laparoscopic cholecystectomy? Literature review. Eleven randomised studies show the superiority of the laparoscopic technique. Only one study shows no advantage provided the length of the incision in the open procedure is less than 8 cm. According to our own experience, up to 98% of all gall bladders can be removed laparoscopically when following the described standard technique, with a conversion rate of less than 1%. In the case of an occult choledocholithiasis the concept of "therapeutic splitting" has proved successful; the risk of a residual stone is below 1%. Routine intraoperative cholangiography is not cost effective. The risk of complications for a silent gall stone in the long term is higher than for laparoscopic cholecystectomy in young patients with incidental gall stones. The laparoscopic technique has given new impulses to the surgery of the gall bladder and has proven to be an effective, patient-friendly alternative to open surgery.

Acute cholecystitis.

Only 20-30% of patients with gallstones have symptoms and the probability of a patient with silent gallstones developing biliary-related pain is 1-2%, while the risk of developing a serious complication (e.g. empyema, perforation, peritonitis etc.) is less than 0.1% per year. Imaging techniques are important in establishing the diagnosis and evaluating the patient. Laparoscopic cholecystectomy (LC) is the golden standard for the management of symptomatic gallstones and there are two surgical treatment options: early cholecystectomy (same hospital admission) and interval (delayed) cholecystectomy (6-8 weeks after resolution of acute attack). Early LC has medical and socioeconomic advantages over interval LC. LC can be undertaken for the majority of patients with AC and in some high risk groups the postoperative mortality can even be reduced. LC in AC is associated with longer operating time, a higher rate of conversion and bile damage. Early diagnosis and early operation can prevent the development of complications associated with AC.