The majority of patients with gallstones are asymptomatic and will remain so throughout their lives. Of those with incidental (asymptomatic) gallstones, approximately 15 to 25 percent will become symptomatic after 10 to 15 years of follow-up.
•Biliary colic
Patients with symptomatic uncomplicated gallstone disease typically present with biliary colic, a normal physical examination, and normal laboratory test results. Biliary colic is an intense, constant, dull discomfort usually located in the right upper quadrant or epigastrium that may radiate to the back (particularly the right shoulder blade). The pain is often associated with diaphoresis, nausea, and vomiting.
●Atypical symptoms
Symptoms other than biliary colic have been reported in patients with gallstones, but their predictive value for the presence of gallstone disease is poor. Atypical symptoms include belching, fullness after meals/early satiety, regurgitation, abdominal distension/bloating, epigastric or retrosternal burning, nausea or vomiting, chest pain, and nonspecific abdominal pain.
●Complications of gallstone disease
Complications include acute cholecystitis, choledocholithiasis with obstruction (with or without acute cholangitis), and gallstone pancreatitis. Rare complications include gallstone ileus, Mirizzi syndrome, and gallbladder cancer.
●Diagnosis
Uncomplicated gallstone disease should be suspected in a patient with biliary colic, a normal physical examination, and normal laboratory tests (complete blood count, aminotransferases, bilirubin, alkaline phosphatase, amylase, and lipase). Such patients should undergo an imaging study to determine if there are gallbladder stones or sludge. Typically, the evaluation begins with a transabdominal ultrasound since it is the most sensitive modality for detecting gallbladder stones. On ultrasound, gallstones appear as echogenic foci that cast an acoustic shadow and seek gravitational dependency.
In patients with typical biliary colic but no gallstones on ultrasonography, we usually repeat the transabdominal ultrasound in a few weeks to detect missed gallstones. If the repeat transabdominal ultrasound is negative, the decision to pursue additional evaluation with endoscopic ultrasound and, if needed, bile microscopy to detect sludge or microlithiasis depends on the patient’s preferences, availability of endoscopic expertise, and risk factors for adverse outcomes with sedation and endoscopy.
●Natural history
Patients with asymptomatic gallstones appear to have a lower risk of complications than those with symptomatic gallstones. Once a complication develops, the risk of additional, often more severe complications is approximately 30 percent per year.
