Associate Professor Gregory L Falk ( left ) Associate professor of surgery , Sydney Heartburn Clinic , Lindfield , NSW ; Concord General Repatriation Hospital , Concord , NSW ; Sydney Adventist Hospital , Wahroonga , NSW .

Fienne Sime ( right ) Oesophageal physiology technician , Sydney Heartburn Clinic , Lindfield , NSW .

First published online on 1 December 2023

INTRODUCTION

GALLSTONES are a common affliction

in Western society , with the prevalence ranging up to 50 %. 1 Many patients with gallstones are asymptomatic ; however , gallstones have a significant potential to cause symptoms and complications . These include common bile duct stones , ascending cholangitis and septicaemia , cholecystitis , gallstone pancreatitis and jaundice ( see figure 1 ). They are an insidious cause of pyrexia of unknown origin in the elderly .

Complicated gallstone disease is usually treated by cholecystectomy , and symptomatic uncomplicated gallbladder disease is a relative indication for surgery . The jury is out regarding the ideal management of asymptomatic gallstones , and the age of the patient is a significant factor when considering treatment options .

This How to Treat discusses the diagnostic symptoms of gallbladder disease and aims to ensure GPs can appropriately investigate and confirm the presence of symptomatic gallstones .

DIAGNOSIS

History

THE nature of the pain is paramount

to diagnosis .

BILIARY COLIC The most frequent presentation of symptomatic gallstones in general practice is the patient who has had one or more episodes of significantly uncomfortable upper abdominal and lower chest discomfort ( see figure 2 ). Differential diagnosis may be difficult , with other conditions such as constipation , irritable bowel , reflux disease , peptic ulceration and gastric motility disorders requiring consideration . Myocardial ischaemia must also be excluded .

Biliary colic is characteristically severe , unpredictable and episodic . It occurs centrally in the epigastrium or behind the lower third of the sternum , tends to last longer than 20-30 minutes and may radiate into the scapula or to the shoulder tip or jaw . It tends to be difficult for the patient to describe . The colic frequently comes on in the middle of the night and wakes the patient from sleep . It tends not to be burning in nature but may be .

The pain may persist with exacerbations ( colic ) and is frequently associated with bloating , belching , nausea and vomiting and , occasionally , diarrhoea . Pain may be felt in the right upper quadrant , but most

commonly is epigastric in nature . The pain is frequently described as “ a band around the lower chest ”, and so these patients are often seen in ED as a possible acute MI , and the diagnosis of gallstones is frequently not made .

If a patient returns from ED with the obscure diagnosis of ‘ oesophageal spasm ’, it is more than likely the patient has gallbladder disease .

CHOLECYSTITIS Cholecystitis may occur because of gallstones ( see figure 3 ). Patients usually present with biliary colic , right upper quadrant pain , fever , and abdominal tenderness in the epigastrium and underneath the right rib . It may be painful to cough and to breathe deeply , and examination may reveal tenderness on palpation in the right upper quadrant on inspiration ( Murphy ’ s sign ). Patients frequently present to the ED and to the GP . Disease may be severe , associated with high fevers and septic shock , and can constitute a significant surgical emergency .

COMMON BILE DUCT STONES Gallbladder stones may enter the common bile duct ( CBD ) through

the cystic duct communication , and have the potential to cause bile duct obstruction , pancreatitis or infection . Patients may have associated liver function test abnormalities , appear jaundiced , or have had episodes of dark urine , often associated with an attack of biliary colic . The presence of elevated transaminase is an early and subtle sign of CBD stones and bile duct dilatation seen on ultrasound ( see figure 4 ) is an indirect indicator of the likelihood of CBD stones , although they are directly poorly imaged . 2 , 3

CHOLANGITIS When stones enter the CBD , the risk of infection within the biliary tree increases . The diagnostic criteria are those of pain resembling biliary colic but more prolonged , marked fever , and jaundice ( Charcot ’ s triad ). 4 Severe disease with septicaemia presents with the additional symptoms of hypotension and cerebral confusion ( Reynolds ’ pentad ). 5

Infection in the biliary tree is frequently clinically deceptive in the elderly , with pain frequently a lesser feature . The Tokyo guidelines for use in those with cholangitis replace fever and jaundice with