Gall Stones, Gall-bladder Polyps and Their Complications: Epidemiology, Pathogenesis, Diagnosis, and Management

Gall stones are common in the USA, and diseases associated with gall stones are a significant cause of morbidity and mortality. Cholesterol gall stones are the most common kind in Western populations, resulting primarily from biliary stasis and altered cholesterol metabolism. Risk factors for cholesterol gall stones include advancing age, female gender (especially among people of Hispanic origin), obesity, diabetes, and family history. Gall stones most commonly cause cholecystitis, but can also present as cholangitis, pancreatitis, or symptomatic choledocholithiasis, and uncommonly may result in gall-stone ileus or Mirizzi syndrome. The clinical presentations of gall-stone-related diseases are widely variable, ranging from asymptomatic stones detected incidentally to severe pain with biliary colic or even multisystem failure associated with necrotizing cholecystitis, cholangitis, or pancreatitis. Gall-stone-related diseases can often be diagnosed non-invasively through clinical presentation in concert with ultrasonography, computed tomography, or magnetic resonance cholangiopancreatography. Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis, and may be offered for asymptomatic cholelithiasis in select groups. For choledocholithiasis and its complications, management usually involves both endoscopy and surgery. Endoscopic retrograde cholangiopancreatography (ERCP) is indicated when there is ongoing evidence of choledocholithiasis, unless the surgeon plans intraoperative bile duct clearance. ERCP is usually performed before surgery, but can be performed postoperatively in expert centers where stone extraction is routinely successful. For gall-stone pancreatitis, cholecystectomy should be performed early after recovery from the acute injury to reduce the risk of further episodes of pancreatitis. A laparoscopic approach is preferred, and again may include bile duct clearance, depending on local expertise. Gall-bladder polyps are uncommon and usually identified incidentally by ultrasonography. Polyps are significant in the gall bladder because some have malignant potential; their management is also surgical.