Review

Gallstones: Watch and wait, or intervene?

Mounir Ibrahim, MD, Shashank Sarvepalli, MD, Gareth Morris-Stiff, MD, PhD, Maged Rizk, MD, Amit Bhatt, MD, R. Matthew Walsh, MD, Umar Hayat, MD, Ari Garber, MD, EdD, John Vargo, MD and Carol A. Burke, MD
Cleveland Clinic Journal of Medicine April 2018, 85 (4) 323-331; DOI: https://doi.org/10.3949/ccjm.85a.17035

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Management of patients with gallstones.

    Based on information in reference 48.

  • Figure 2
    Figure 2

    Management of patients with symptomatic bile duct stones (choledocholithiasis).

    Reprinted from ASGE Standards of Practice Committee; Maple JT, Ben-Menachem T, Anderson MA, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endoscp 2010; 71:1–9 with permission from Elsevier.

Tables

  • TABLE 1

    Gallstone risk factors

    Age > 40
    Female sex
     Reproductive age
     Pregnancy or oral contraception use
    Ethnicity (Mexican American, Native American)
    Rapid weight loss (eg, after bariatric surgery)
    Hemolytic anemia
    Diabetes mellitus
    Obesity
  • TABLE 2

    Gallstone complications

    Acute cholecystitis
    Chronic cholecystitis
    Choledocholithiasis
    Acute cholangitis
    Acute pancreatitis
    Empyema in gallbladder
    Obstructive jaundice
    Choledochoduodenal fistula
    Gallbladder perforation

    • Adapted from information in references 18 and 19.

  • TABLE 3

    Asymptomatic gallstones: Outcomes with watchful waiting

    InvestigatorsNo. of patientsFollow-up (months)Developed biliary colicDeveloped complications
    Gracie et al,41 198212325218%2.4%
    McSherry et al,42 1985135  4610%_
    Wada et al,43 199368016020%_
    Attili et al,39 199511812025.8%3%
    Halldestam et al,44 2004120  876.6%5%
    Festi et al,45 201045310421.9%_
    Shabanzadeh et al,46 201666420911.6%8%
  • TABLE 4

    Predictors of bile duct stones

    Predictors
    Very strong
     Ascending cholangitis
     Common bile duct stone on abdominal ultrasonography
     Bilirubin > 4 mg/dL
    Strong
     Dilated common bile duct on abdominal ultrasonography
     Bilirubin 1.8–4 mg/dL
    Moderate
     Age > 55
     Abnormal aminotransferase and gamma-glutamyl transferase levels
     Gallstone pancreatitis
    Likelihood of choledocholithiasis based on predictors
    High (> 50%)
     Presence of any very strong factor
     Presence of 2 strong factors
    Intermediate (10% to 50%)
     All other patients
    Low (< 10%)
     No predictors present

    • Adapted from reference 31.

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