Gallstones (and polyps)

Overview

Introduction

• A gallstone (cholelithiasis) is a solid deposit that forms within the gallbladder.
• Most gallstones (over 90%) in developed countries consist of cholesterol.
• Gallstone disease is a general term that describes the presence of one or more stones in the gallbladder or other parts of the biliary tree, and the symptoms and complications they may cause.
• In some people, one or more gallstones pass out of the gallbladder into the cystic duct, the common bile duct or the pancreatic duct.
• Cholecystolithiasis describes gallstones in the gallbladder.
• Choledocholithiasis describes gallstones in the common bile duct.
• Most people with gallstone disease (80%) are asymptomatic and will never know that they have gallstones.

Diagnosis

• Suspect gallstone disease in people who present with the classical symptoms and signs of symptomatic gallstone disease, or complications of gallstone disease.
  • Biliary colic — this is the most common presentation. Steady non-paroxysmal biliary pain occurs in the epigastrium or right upper quadrant and typically lasts for more than 30 minutes, but less than eight hours. It is often severe, and may be associated with nausea and vomiting, but is not associated with fever, or abdominal tenderness.
  • Acute cholecystitis — this is the second most common presentation. Classical symptoms and signs are similar to biliary colic, but in addition other classical features are fever and tenderness in the right upper quadrant.
  • Obstructive jaundice — yellowish discolouration of the skin, dark urine and pale stools.
  • Cholangitis — typical features, referred to as Charcot's triad, are diagnostic: fever (often with rigors), jaundice, and upper quadrant abdominal pain.
  • Gallstone pancreatitis — constant epigastric pain radiating through to the back, and profuse vomiting.
  • Various other complications can cause a variety of symptoms.
• Some people with gallstone disease do not have classical symptoms or signs and present with mild and varied symptoms such as indigestion, intolerance to fried or fatty food, or epigastric pain.
  • Consider gallstone disease in any person with any abdominal symptom that is not confirmed to be due to another cause.
• Gallstones may be detected as an incidental finding whilst a person has tests such as an abdominal ultrasound or x-ray examination for unrelated reasons.

Who to Refer

Please see the BNSSG's Gallbladder Removal in Adult Patients – Over 18 Years Criteria Based Access Policy for details on who to refer.

Cholecystectomy for symptomatic gallstones is subject to this policy and referrals not meeting the criteria within the policy will be returned to the referrer.

Cholecystectomy for asymptomatic or incidental gall stones is not usually required and referral is not routinely funded unless exceptions apply - see policy for details.

Red Flags

If there is suspicion of any of the following, consider admission via ED or immediate referral or discussion with the surgical team as appropriate- see surgical emergency care:

• haemodynamic compromise
• acute abdomen
  • guarding indicates localised/generalised peritonitis
  • acute intestinal obstruction (rare)
• acute cholecystitis
  • persistent right upper quadrant (RUQ)/epigastric pain with marked tenderness
  • a positive Murphy’s sign:
    • indicative of inflammation associated with acute cholecystitis
    • elicited by asking the patient to inspire deeply with the examining hand immediately below the right costal margin in the mid-clavicular line
    • an inflamed gallbladder is indicated by patient experiencing pain and catching their breath as the gallbladder descends
    • low-grade pyrexia (high-grade pyrexia may indicate cholangitis)
  • delayed presentation with systematic sepsis from gallbladder abscess (empyema) and rarely perforation
• jaundice
  
  • gallstones associated with painful jaundice indicates obstruction of the common bile duct by a gallstone migrating from the gallbladder
  • rarely, a large stone resident in the gallbladder may compress the biliary tree to present in a similar fashion (Mirrizi's syndrome)
  • painless jaundice is rarely attributable to gallstone pathology
  • patients may complain of pale stool and/or dark urine
• acute cholangitis
  • Charcot’s triad of jaundice, epigastric or RUQ pain, and fever (typically with rigors) is diagnostic
  • indicates super-added infection of the obstructed biliary system
• acute pancreatitis
  • severe epigastric pain that may radiate to the back
  • vomiting
  • difficult diagnosis to make in primary care, but should be considered in all unwell patients with a history of gallstones.

Gall bladder cancer

Refer via Upper GI - USC (2WW) pathway if imaging (USS or CT) indicates possible gallbladder cancer.

Before Referral

Management of Symptomatic Gallstones

• Patients with symptoms of nausea / pain should be assessed for red flags (see above). If immediate assessment in secondary care is not required, then manage in primary care in the first instance.
• Offer appropriate pain relief and recommend a low-fat diet in all patients presenting with biliary pain.
• Abdominal USS and bloods (including LFTs) should be performed.
• The absence of gallstones on USS does not exclude their existence and referral (for MRCP or endoscopic US) should be considered if clinical suspicion remains high.
• Referrals should only be made in line with the criteria based access policy following a second episode of bilary colic (pain and / or nausea) or if there are other indications as listed in the funding policy above.

Management of Asymptomatic Gallstones

Patient who have gallstones which are asymptomatic or diagnosed as an incidental finding, do not fulfill criteria for referral.

NICE recommends that no treatment is required for the management of asymptomatic gallstones when found in a normal gallbladder, and with a normal biliary tree,  a watch-and-wait approach is recommended for asymptomatic gallstones, with referral for active treatment only recommended if the stones begin to cause symptoms or if the patient has one of the following:

• Sickle Cell disease or other chronic haemolytic diseases
• An increased risk of developing complications (with non-functioning gallbladder, choledocholithiasis and obstructive jaundice).

Gallbladder Polyps

Management of Gallbladder polyps

Gallbladder polyps are usually asymptomatic but are sometimes picked up when investigating patients with abdominal pain or as an incidental finding on abdominal imaging (2). However some patients with polyps may be at risk of malignancy and surgery or monitoring may therefore be required.

Monitoring and referral guidelines are summarised in the ESGAR guidelines as below.

ESGAR Guidelines

Please refer to the ESGAR (European Society of Gastrointestinal and Abdominal Radiology) guidelines. These guidelines were last reviewed in 2021 and the pathway was published in European Radiology: 

Management and follow-up of gallbladder polyps - pathway on page 3361.

Referral and BNSSG Funding Policy

Referral for cholecystectomy should be considered depending on size of the polyp(s), symptoms (if no alternative cause) and risk factors for malignancy as described in the guidelnes above. Prior to considering a referral, please also see the Gallbladder Removal in Adult Patients – Over 18 years Criteria Based Access Policy 

Referral

Referrals demonstrating that the criteria within the policy have been met should be made via e-RS.

A full choice of NHS providers can be found on the BNSSG Service Guide. (see under GI and Liver - Gallstones/Cholecystectomy). A choice of provider will be offered where appropriate and if exclusions do not apply, unless a specific provider is requested.

Pre-operative Assessment - although not a condition for referral, please provide pre-operative information regarding your patient in the referral if possible and address operative risks where appropriate. This may help reduce delays in obtaining treatment for your patient.

Resources

(1) NICE Clinical Knowledge Summaries - Gallstones

(2) gallbladder polyp - General Practice notebook (gpnotebook.com)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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