Evidence-based clinical practice guidelines for cholelithiasis

Key points

Overview

The JSGE guidelines give flowcharts for the diagnosis and treatment of gallbladder stones, CBDS and intrahepatic stones (hepatolithiasis), to support gastroenterologists and general physicians. The literature search covered MEDLINE, the Cochrane Library and Igaku Chuo Zasshi from 1983 to August 2019, with an additional manual search. Evidence was graded A (high) to D (very low), and the strength of each recommendation was set by committee voting that considered benefits and harms, patient preference and cost; consensus required at least 70% of the votes.

Causes and natural history

Cholesterol stones form through cholesterol supersaturation of bile, crystallisation and reduced gallbladder contractility. The classic risk factors (forty, female, fatty, fair and fertile) remain strong, together with dyslipidaemia, previous upper gastrointestinal or bariatric surgery and diet. In asymptomatic gallbladder stones, the cumulative rate of becoming symptomatic over 10 years is estimated at about 10–20%. There is no clear evidence that gallbladder stones are a risk factor for gallbladder cancer (no recommendation, evidence level D), whereas hepatolithiasis is a strong risk factor for intrahepatic cholangiocarcinoma.

Diagnosis

Abdominal ultrasound and blood tests come first when gallbladder stones are suspected. CT, MRI/MRCP and/or EUS are recommended when the gallbladder is poorly seen or findings are indeterminate, and when cholangitis or CBDS, Mirizzi syndrome, confluence stones or gallbladder cancer is suspected. Acute cholecystitis is diagnosed from local signs, systemic inflammation and imaging, and its severity is graded by organ dysfunction and local inflammation. For suspected CBDS, ERCP is recommended when symptoms of acute cholangitis are present. In a meta-analysis of four randomised trials, an EUS-first strategy avoided ERCP in 67.1% of patients and reduced overall adverse events (relative risk 0.35) and post-procedure pancreatitis (relative risk 0.21). In suspected hepatolithiasis, blood tests, ultrasound, CT, MRI and MRCP are used, and tumour markers are measured to assess the risk of intrahepatic cholangiocarcinoma.

Treatment of gallbladder stones

Butylscopolamine, flopropione and non-steroidal anti-inflammatory drugs are used for attacks, and oral ursodeoxycholic acid is an option to prevent them; extracorporeal shock wave lithotripsy and oral dissolution therapy are now rarely used. Patients at high risk of gallbladder cancer include those with stones larger than 3 cm, polyps larger than 10 mm, a porcelain gallbladder, a thickened gallbladder wall or a stone-filled gallbladder (cholecystectomy should be considered: weak recommendation, evidence level C). In a 2017 Japanese survey, laparoscopic cholecystectomy caused bile duct injury in about 0.4% of cases, bleeding requiring laparotomy in 0.3% and injury to other organs in 0.3%. In severe acute cholecystitis, systemic antibacterial treatment comes first; early cholecystectomy by a skilled surgeon at a tertiary institution is recommended (weak, evidence level B), and early gallbladder drainage is recommended if the patient cannot withstand early surgery (strong, evidence level A). Surgery is recommended for Mirizzi syndrome (strong, evidence level D), and endoscopic treatment with oral cholangioscopy at a well-equipped centre is suggested for confluence stones (weak, evidence level D).

Treatment of bile duct stones

The standard endoscopic treatment is endoscopic sphincterotomy (EST) followed by stone extraction, and endoscopic papillary balloon dilation (EPBD) is also applicable. For difficult stones, options include endoscopic papillary large balloon dilation, peroral cholangioscopy, percutaneous transhepatic cholangioscopy, balloon endoscopy-assisted techniques and EUS-guided procedures. When CBDS occur with gallbladder stones, endoscopic stone removal followed by cholecystectomy and one-stage surgical treatment are equally effective for duct clearance, residual stones, mortality and complications, apart from a longer hospital stay with the two-stage approach; in Japan, 80% of CBDS are treated in two stages.

Frequently asked questions

Should asymptomatic gallbladder stones be removed?

Generally not. Prophylactic cholecystectomy is not recommended, but it should be considered in patients at high risk of gallbladder cancer; others are followed up with periodic examinations such as abdominal ultrasound.

Which gallbladder drainage is recommended in acute cholecystitis?

PTGBD is recommended. Endoscopic drainage by a skilled endoscopist is proposed for patients with coagulopathy, those taking antithrombotic drugs and those with ascites. EUS-guided gallbladder drainage has shown good results but was not yet included in the recommendations.

When is EUS used before ERCP?

In suspected CBDS when ultrasound, CT and/or MRI/MRCP are indeterminate (weak recommendation, evidence level B).

Source

Fujita N, Yasuda I, Endo I, et al. Evidence-based clinical practice guidelines for cholelithiasis 2021. J Gastroenterol 2023;58(9):801-833. DOI: 10.1007/s00535-023-02014-6. Open access. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.