Gallstone disease natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Natural History, Complications, and Prognosis

Natural History

A study was conducted on a cross-section of middle income Americans to examine the natural history of gallstones. The study had a total of 691 patients. Of the 691 patients, 556 (80.5%) patients exhibited symptoms attributable to gallbladder disease and the other 135 (9.5%) patients were asymptomatic. In the symptomatic group, 242 (44%) eventually underwent a cholecystectomy in order to relieve their persistent symptoms. Only 10% of the asymptomatic group developed symptoms of gallstones, and 7% required a cholecystectomy. In total, there were 50 deaths in this series of 691 patients, 25 in the symptomatic group and 25 in the asymptomatic. Only 2 of these deaths were related to gallstone disease. This study therefore concluded that silent (asymptomatic) stones do not need to operated on until symptoms develop. The study also found that patients usually tolerated their symptoms for very long periods of time and would not readily undergo surgery.

Complications

• Common complications of gallbladder disease include:
  • Acute cholecystitis
  • Gallbladder perforation
  • Obstructive jaundice
  • Choledocholithiasis with or without acute cholangitis
  • Gallbladder fistula
  • Cholangiocarcinoma
  • Gallstone pancreatitis
  • Gallstone ileus

Prognosis

Less than half of patients with gallstones become symptomatic. The mortality rate for an elective cholecystectomy is 0.5% with less than 10% morbidity. The mortality rate for an emergent cholecystectomy is 3-5% with 30-50% morbidity. Following cholecystectomy, stones may recur in the bile duct. Separately, single-incisional laparoscopic cholecystectomy appears to be associated with an incisional hernia rate of 8%, with age (≥50 years) and body mass index (BMI) (≥30 kg/m2) as independent predictive factors. [8] Approximately 10-15% of patients have an associated choledocholithiasis. The prognosis in patients with choledocholithiasis depends on the presence and severity of complications. Of all patients who refuse surgery or are unfit to undergo surgery, 45% remain asymptomatic from choledocholithiasis, while 55% experience varying degrees of complications.