MEDizzy - A 44-year-old woman is evaluated for complaints of abdominal

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A 44-year-old woman is evaluated for complaints of abdominal pain. She describes the pain as a postprandial burning pain. It is worse with spicy or fatty foods and is relieved with antacids. She is diagnosed with a gastric ulcer and is treated appropriately for H pylori. During the course of her evaluation for her abdominal pain, the patient had a right upper quadrant ultrasound that demonstrated the presence of gallstones. Following treatment of H pylori, her symptoms have resolved. She is requesting your opinion regarding whether treatment is required for the finding of gallstone disease. Upon review of the ultrasound report, there were numerous stones in the gallbladder, including in the neck of the gallbladder. The largest stone measures 2.8 cm. What is your advice to the patient regarding the risk of complications and the need for definitive treatment?

ExplanationIn the National Health and Nutrition Examination Survey, the prevalence of gallstone disease in the United States was 7.9% in men and 16.6% in women. Although the disease is quite prevalent, not all patients with gallstone disease require cholecystectomy. It is estimated that 1%–2% of patients with asymptomatic gallstone disease will develop complications that will require surgery yearly. Therefore, it is important to know which patients with asymptomatic gallstones require referral for surgery. The first factor to consider is whether the patient has symptoms that are caused by gallstones and are frequent enough and severe enough to necessitate surgery. Commonly called biliary colic, the classic symptoms of gallstone disease are right upper quadrant pain and fullness that begins suddenly and can last as long as 5 hours. Nausea and vomiting can accompany the episode. Vague symptoms of epigastric fullness, dyspepsia, and bloating following meals should not be considered biliary colic. A second factor that would be considered in recommending a patient for cholecystectomy is whether the patient has a prior history of complications of gallstone disease such as pancreatitis or acute cholecystitis. A final factor that would lead to the recommendation for cholecystectomy is the presence of anatomical factors that would increase the likelihood of complications such as a porcelain gallbladder or congenital abnormalities of the biliary tract. Individuals with very large stones (>3 cm) would also need to be considered carefully for cholecystectomy. Ursodeoxycholic acid can be used in some instances to dissolve gallstones. It acts to decrease the cholesterol saturation of bile and also allows the dispersion of cholesterol from stones by producing a lamellar crystalline phase. However, it is only effective in individuals with radiolucent stones measuring less than 10 mm.