Guideline sources The following summarized guidelines for the evaluation and management of gallstone disease are prepared by our editorial team based on guidelines from the Danish Surgical Society (DSS 2022), the American Society of Anesthesiologists (ASA/ACE/OS/AACE/ASMBS/OMA 2020), the World Society of Emergency Surgery (WSES 2020), the American College of Radiology (ACR 2019), the North American Neuroendocrine Tumor Society (NANETS 2017), the Japanese Society of Gastroenterology (JSG/JBA/JGES 2017), the European Association for the Study of the Liver (EASL 2016), the American Society for Gastrointestinal Endoscopy (ASGE 2015; 2010), the American Association of Family Physicians (AAFP 2014), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES 2010). 1 2 3 4 5 6 7 8 9 10 11 Calculator Calculator CholeS score for duration of lap Diagnostic criteria for acute chol https://web.pathway.md/diseases/recS6g9oRq28F02Qm 1/7 6/24/23, 2:54 AM Gallstone disease Pathway Guidelines 1. Diagnostic investigations History and physical examination: elicit medical history and perform a physical examination to identify characteristic findings of gallbladder stones (episodic attacks of severe pain in the right upper abdominal quadrant or epigastrium for at least 15-30 minutes with radiation to the right back or shoulder and a positive reaction to analgesics). B Diagnostic imaging: As per WSES 2020 guidelines, obtain abdominal ultrasound as the preferred initial imaging technique for gallstone disease due to its cost-effectiveness, wide availability, reduced invasiveness, and good accuracy. A As per ACR 2019 guidelines: Obtain abdominal ultrasound as initial evaluation in patients with RUQ pain with suspected biliary disease. B Obtain abdominal MRI (with or without IV contrast) with MRCP or contrast-enhanced abdominal CT in patients with RUQ pain with suspected biliary disease in the setting of negative or equivocal ultrasound and in the absence of fever or leukocytosis. B As per EASL 2016 guidelines: Obtain abdominal ultrasound in patients with a recent history of biliary pain. A Consider obtaining EUS or MRI in case of strong clinical suspicion of gallbladder stones and negative abdominal ultrasound. C As per AAFP 2014 guidelines, obtain abdominal ultrasound as initial imaging in patients with suspected gallstones or complications of gallstones. B As per ASGE 2010 guidelines, proceed to cholecystectomy without additional biliary evaluation in patients with symptomatic cholelithiasis being surgical candidates and having a low probability of choledocholithiasis. B Laboratory tests: Do not obtain routine laboratory tests in addition to abdominal ultrasound to confirm the presence of gallstones. D Consider obtaining liver biochemical tests in individually selected cases. C 2. Medical management Expectant management: As per DSS 2022 guidelines, consider offering observation as an alternative to laparoscopic cholecystectomy in patients with uncomplicated gallstone disease. C As per JSG 2017 guidelines: https://web.pathway.md/diseases/recS6g9oRq28F02Qm 2/7 6/24/23, 2:54 AM Gallstone disease Pathway Do not offer treatment in asymptomatic patients with fully evaluable gallbladder walls. D Obtain annual follow-up, including physical examination, abdominal ultrasound, and other modalities as appropriate, in patients with gallstones because of the risk for hepatic dysfunction or gallbladder cancer. B As per EASL 2016 guidelines, do not offer routine treatment in patients with asymptomatic gallbladder stones. D As per AAFP 2014 guidelines, offer expectant management in patients with incidentally detected, asymptomatic gallstones. B Bile acid litholysis: As per JSG 2017 guidelines: Offer oral dissolution therapy in patients with gallstone disease refusing surgery. B Offer oral dissolution therapy with bile acid formulations in patients with radiolucent cholesterol gallstones with normal gallbladder function. B As per EASL 2016 guidelines, do not offer litholysis using bile acids alone or in combination with extracorporeal shock wave lithotripsy in patients with gallbladder stones. D Management of pain: administer NSAIDs (such as diclofenac, indomethacin) for the treatment of biliary colic. B 3. Therapeutic procedures Extracorporeal shock wave lithotripsy: As per JSG 2017 guidelines: Offer extracorporeal shock wave lithotripsy in patients with gallstone disease refusing surgery. B Offer extracorporeal shock wave lithotripsy in patients with non-calcified cholesterol gallstones with normal gallbladder function. B As per EASL 2016 guidelines, do not offer extracorporeal shock wave lithotripsy in patients with gallbladder stones. D 4. Perioperative care Perioperative antibiotic prophylaxis: As per EASL 2016 guidelines, do not administer routine antibiotic prophylaxis before elective laparoscopic cholecystectomy. D As per AAFP 2014 guidelines, do not administer antibiotic prophylaxis in low-risk patients undergoing elective laparoscopic cholecystectomy. D 5. Surgical interventions https://web.pathway.md/diseases/recS6g9oRq28F02Qm 3/7 6/24/23, 2:54 AM Gallstone disease Pathway Cholecystectomy, indications: As per JBA/JGES/JSG 2017 guidelines, perform cholecystectomy in patients with cholecystolithiasis presenting with any symptoms. B As per EASL 2016 guidelines, perform cholecystectomy as the preferred option for the treatment of patients with symptomatic gallbladder stones. B Show 5 more As per SAGES 2010 guidelines, perform laparoscopic cholecystectomy in patients with symptomatic cholelithiasis. B Cholecystectomy (timing): Perform cholecystectomy as early as possible in patients with uncomplicated biliary colic. B Perform early laparoscopic cholecystectomy, within 72 hours after preoperative ERCP for choledocholithiasis, in patients with simultaneous gallbladder and bile duct stones. B Cholecystectomy, choice of approach: As per JBA/JGES/JSG 2017 guidelines, perform laparoscopic cholecystectomy as the first- choice surgical procedure in institutions with adequate experience. A Show 2 more As per EASL 2016 guidelines, perform laparoscopic cholecystectomy as the standard method of cholecystectomy in patients with symptomatic gallbladder stones. A Show 4 more As per AAFP 2014 guidelines, perform laparoscopic cholecystectomy as the standard treatment in patients with gallstone disease. A Cholecystectomy (technical considerations): recognize that day-surgery may be as safe as overnight stay laparoscopic cholecystectomy in patients without systemic disease. B Show 2 more Cholecystectomy (management of postoperative leaks): perform ERCP as first-line therapy for postoperative biliary leaks. A 6. Specific circumstances Elderly patients: Perform cholecystectomy in the elderly and in patients with high anesthetic risk with gallstone complications (such as acute cholecystitis, gallstone pancreatitis, or obstructive jaundice) as soon as the general status allows surgery. B Do not withhold laparoscopic cholecystectomy solely based on the chronological age. D Pregnant patients: As per EASL 2016 guidelines, perform laparoscopic cholecystectomy during pregnancy in case of urgent indication, regardless of trimester. B Show 2 more https://web.pathway.md/diseases/recS6g9oRq28F02Qm 4/7 6/24/23, 2:54 AM Gallstone disease Pathway As per AAFP 2014 guidelines, perform laparoscopic cholecystectomy when indicated, during any trimester of pregnancy. A Patients undergoing bariatric surgery: As per AACE 2020 guidelines: Initiate oral UDCA to reduce the risk of cholelithiasis due to rapid weight loss in patients undergoing sleeve gastrectomy, Roux-en-Y gastric bypass, or biliopancreatic diversion with duodenal switch (500 mg once daily for sleeve gastrectomy and 300 mg BID for Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch). A Consider performing prophylactic cholecystectomy to avoid choledocholithiasis in asymptomatic patients with known gallstones and a history of Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch, since traditional ERCP can no longer be performed in these patients. C As per EASL 2016 guidelines, consider offering UDCA to prevent cholesterol gallstone formation in patients on long-term therapy with somatostatin or analogs. C Show 2 more 7. Preventative measures Primary prevention (lifestyle interventions): consider advising healthy lifestyle and food, regular physical activity, and maintenance of ideal body weight to prevent the formation of cholesterol gallbladder stones and symptomatic gallstones. C Primary prevention, pharmacological interventions: As per ASA/OMA/ASMBS/OS/ACE/AACE 2020 guidelines, initiate oral UDCA to reduce the risk of cholelithiasis due to rapid weight loss in patients undergoing sleeve gastrectomy, Roux-en-Y gastric bypass, or biliopancreatic diversion with duodenal switch (500 mg once daily for sleeve gastrectomy and 300 mg BID for Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch). A As per EASL 2016 guidelines, do not offer pharmacological prevention of gallstones in the general population. D Show 4 more Prophylactic cholecytectomy: As per NANETS 2017 guidelines, perform prophylactic cholecystectomy at the time of index surgery in patients with gastrointestinal NETs if there is a high likelihood that long-term therapy with somatostatin analogs will be required (such as in patients with liver metastases, peritoneal disease, or significant nodal involvement). Do not perform prophylactic cholecystectomy in asymptomatic patients receiving somatostatin analogs after primary tumor removal without cholecystectomy. Consider delaying cholecystectomy until a future abdominal procedure is planned (such as hepatic cytoreduction), or until symptoms of biliary colic or complications from embolization develop. E https://web.pathway.md/diseases/recS6g9oRq28F02Qm 5/7 6/24/23, 2:54 AM Gallstone disease Pathway As per EASL 2016 guidelines, do not perform routine prophylactic cholecystectomy in patients undergoing bariatric surgery. D 8. Follow-up and surveillance Discharge from hospital: consider discharging patients undergoing uncomplicated laparoscopic cholecystectomy on the day of surgery. Ensure adequate control of postoperative pain, nausea, and vomiting for successful same-day discharge. C Management of postoperative bile duct injury: obtain urgent investigation including laboratory tests (WBC, bilirubin, LFTs) and imaging (abdominal ultrasound, contrast-enhanced CT, MRCP) to detect bile leak and/or intra-abdominal fluid in patients suspected bile duct injury after surgery, while keeping the patient in hospital under close observation. B Show 2 more Management of persistent symptoms: Consider obtaining EUS or MRCP in the diagnostic evaluation of patients with biliary symptoms after cholecystectomy. C Do not perform endoscopic sphincterotomy in patients with abdominal pain after cholecystectomy without significant abnormalities on imaging or laboratory studies. D References 1. EASL. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. 2016 Jul;65 1 146 181. Open 2. James R Howe, Kenneth Cardona, Douglas L Fraker et al. The Surgical Management of Small Bowel Neuroendocrine Tumors: Consensus Guidelines of the North American Neuroendocrine Tumor Society. Pancreas. 2017 Jul;46 6 715 731. Open 3. ASGE Standards of Practice Committee, Krishnavel V Chathadi, Vinay Chandrasekhara et al. The role of ERCP in benign diseases of the biliary tract. Gastrointest Endosc. 2015 Apr;81 4 795 803. Open 4. ASGE Standards of Practice Committee, John T Maple, Tamir Ben-Menachem et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010 Jan;71 1 1 9. Open 5. D Wayne Overby, Keith N Apelgren, William Richardson et al. SAGES guidelines for the clinical application of laparoscopic biliary tract surgery. Surg Endosc. 2010 Oct;24 10 2368 86. Open 6. Expert Panel on Gastrointestinal Imaging:, Christine M Peterson, Michelle M McNamara et al. ACR Appropriateness Criteria Right Upper Quadrant Pain. J Am Coll Radiol. 2019 May;16 5S S235 S243. Open 7. Susumu Tazuma, Michiaki Unno, Yoshinori Igarashi et al. Evidence-based clinical practice guidelines for cholelithiasis 2016. J Gastroenterol. 2017 Mar;52 3 276 300. Open 8. Jeffrey I Mechanick, Caroline Apovian, Stacy Brethauer et al. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures https://web.pathway.md/diseases/recS6g9oRq28F02Qm 6/7 6/24/23, 2:54 AM Gallstone disease Pathway 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity Silver Spring). 2020 Apr;28 4 O1 O58. Open 9. Michele Pisano, Niccol Allievi, Kurinchi Gurusamy et al. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg. 2020; 15 61. Open 10. Sherly Abraham, Haidy G Rivero, Irina V Erlikh et al. Surgical and nonsurgical management of gallstones. Am Fam Physician. 2014 May 15;89 10 795 802. Open 11. Daniel M nsted Shabanzadeh, Dorthe Wiinholdt Christensen, Caroline Ewertsen et al. National clinical practice guidelines for the treatment of symptomatic gallstone disease: 2021 recommendations from the Danish Surgical Society. Scand J Surg. 2022 Aug 24;14574969221111027. Open 12. Hina Arif-Tiwari, MDa, Kristin K. Porter et al. ACR Appropriateness Criteria Abnormal Liver Function Tests. ACR. 2023. Open https://web.pathway.md/diseases/recS6g9oRq28F02Qm 7/7