The gallbladder serves to store and concentrate bile until its secretion is stimulated by the ingestion of a fat-containing meal. Bile contains lecithin, bile salts, and cholesterol—an imbalance in the ratio of these components leads to the precipitation of stones, known as cholelithiasis. It is estimated that more than 15 % of the population has gallstones, but only a minority of these individuals will ever become symptomatic during their lifetime. Therefore, the incidental finding of cholelithiasis in an asymptomatic patient is not an indication for surgery. However, gallstones can cause several disorders that do warrant surgery.

Biliary colic describes the symptoms caused when a gallstone transiently occludes the cystic duct. This obstruction leads to distension of the gallbladder and causes intense right upper quadrant pain, accompanied by nausea and vomiting. The pain lasts for approximately 4–6 h and is self-limited, resolving when the offending stone becomes dislodged. It is important to note that in biliary colic no infection is present, and accordingly the patient will have no fever, tenderness, or leukocytosis. The treatment of biliary colic is bowel rest and intravenous hydration until the event passes, and elective cholecystectomy to prevent future attacks.

Cholecystitis occurs when the stone occluding the cystic duct remains impacted, leading to stasis and infection of the bile within the gallbladder. As opposed to biliary colic, the pain of cholecystitis does not abate, and can last for days if no treatment is provided. Since infection is present, the patient will often display fever and leukocytosis. On examination, the inflamed gallbladder will cause pain on palpation of the right upper quadrant. Since the gallbladder lies under the rib cage, a special maneuver may be necessary to elicit this tenderness. A Murphy’s Sign is performed by asking the patient to take a deep breath while the examiner is pressing into the right upper quadrant. The sign is positive when the patient has an arrest of inspiratory effort, due to the sudden pain caused by the descending gallbladder meeting the examiner’s hand. The treatment of cholecystitis is bowel rest, intravenous antibiotics, and prompt cholecystectomy. If the operation cannot be performed expeditiously, then antibiotics alone will usually cause resolution of the infection and the patient can undergo surgery at a later date. However, this approach leads to a longer and more costly hospital course.

Occasionally a patient with cholecystitis is too acutely ill to undergo immediate cholecystectomy. This is unusual but may be the case in elderly, hospitalized patients with multiple comorbidities. In this circumstance, it may be more prudent to temporarily decompress the gallbladder with a cholecystostomy tube (Fig. 7.1). This minimally invasive procedure drains the infected bile, allowing the cholecystitis to resolve. However, as long as the offending stone remains impacted in the cystic duct, the cholecystostomy tube cannot be removed or else the cholecystitis will recur. Most patients can undergo cholecystectomy in a few weeks, once their underlying medical issues have been stabilized.

If a stone from the gallbladder escapes into the common bile duct, this is termed choledocholithiasis (Fig. 7.2). Most stones that are less than 1 cm in diameter will pass through the Ampulla of Vater and exit into the duodenum without incident. However, there are two potentially severe complications of choledocholithiasis: cholangitis and gallstone pancreatitis. If instead of passing smoothly though the ampulla, the stone becomes lodged and causes biliary obstruction, infection of the static bile will result in cholangitis. Because the infected area includes the entire intrahepatic biliary tree, cholangitis rapidly progresses to bacteremia and sepsis, and can be fatal. Decompression of the biliary tree is urgently required for the treatment of cholangitis. Three different routes can be used to access the bile duct; in order of increasing invasiveness, these are endoscopic retrograde cholangiography, percutaneous transhepatic drainage, or operative common bile duct exploration. While intravenous antibiotics are also administered for cholangitis, they alone are insufficient without drainage of the biliary tree. Once the acute infection has resolved, cholecystectomy is performed to prevent future episodes.

Another serious complication of choledocholithiasis is gallstone pancreatitis. It is thought that the passage of a stone through the Ampulla of Vater causes irritation of the pancreatic duct with activation of pancreatic zymogens inside the pancreas. Although the stone itself passes into the duodenum, the damage has been done, and pancreatitis ensues. The treatment of gallstone pancreatitis is the same as for pancreatitis of other etiologies, and revolves around supportive care. Antibiotics are not used in uncomplicated cases of pancreatitis since the process is an inflammatory, not an infectious one. Once the acute illness has resolved, cholecystectomy is performed to remove the source of future stones. Cholangitis and gallstone pancreatitis are serious enough conditions that—unlike asymptomatic cholelithiasis—the finding of choledocholithiasis always warrants stone extraction and cholecystectomy, even in the absence of symptoms.