A 40 Year Old Woman With Symptomatic Gall Stone Disease

An otherwise healthy 40-year-old woman sees you because of recurrent abdominal pain. In the past month she has had four episodes of colicky epigastric pain. Each of these episodes has lasted about 30 minutes and has occurred within an hour of eating. Two of the episodes have been associated with sweating and vomiting. None of the episodes have been associated with fever or shortness of breath. There is no history of weight loss. She does not drink alcohol or take any prescription or over-the counter medications. Other than three previous uneventful vaginal deliveries, she has never been hospitalized.
Her examination is negative except for mild obesity (BMI = 32).
On investigation a complete blood count and liver function test is normal. A gallbladder sonogram reveals multiple gallstones.

What is the next best step in the treatment of this patient?

a. Omeprazole, 20 mg daily for eight weeks.
b. Ursodeoxycholic acid
c. Observation without specific therapy
d. Laparoscopic cholecystectomy
e. Weight reduction

Answer And Discussion:


The answer is d. (Laparoscopic cholecystectomy.)

Cholelithiasis (gallstone disease) is very common.

Risk factors for the development of gallstones include

• advancing age, 
• female gender, 
• obesity, 
• prior pregnancies, 
• native American or Mexican American ancestry, and 
• rapid weight loss. 

Many patients are asymptomatic but some develop biliary colic. About half of symptomatic patients will have recurrent episodes, and 1% to 2% will develop complications annually.
The treatment of choice is cholecystectomy, which can usually be performed laparoscopically.

This woman’s symptoms are classic for biliary colic; acid reducers such as omeprazole would not be useful. Although ursodeoxycholic acid can dissolve gallstones, they usually recur, and this drug
is no longer considered appropriate therapy unless surgery is contraindicated. Weight reduction does not dissolve gallstones, and rapid weight loss can precipitate symptoms.

In order to prevent complications, symptomatic patients with low operative risk are usually managed with surgery rather than with observation. Asymptomatic gallstone disease is followed and treated surgically if symptoms develop.