A 78-year-old man is evaluated for gallstones. The patient has a history of benign prostate hyperplasia and was admitted to the hospital earlier today with lower abdominal discomfort and difficulty voiding. Evaluation revealed a distended urinary bladder and serum creatinine of 1.3 mg/dL. A urinary catheter was placed, draining 400 mL of cloudy urine. He was started on empiric antibiotics and an alpha-adrenergic antagonist. Abdominal ultrasonography revealed no hydronephrosis, but 2 large gallstones were seen with no gallbladder wall thickening or dilation of the common bile duct. The patient has had intermittent abdominal bloating and mild nausea in the past but reports no fever, chills, pain in the right upper quadrant, or jaundice. Other medical problems include hypertension and type 2 diabetes mellitus.
Temperature is 36.6 C (98 F) , blood pressure is 144/83 mm Hg, and pulse is 78/min. BMI is 44 kg/m². Physical examination reveals mild suprapubic and epigastric tenderness on deep palpation, which does not accentuate on inspiration. There is no rebound tenderness.
Laboratory results are as follows:
Which of the following is the best next step in management of this patient's gallstones?

Question

A 78-year-old man is evaluated for gallstones. The patient has a history of benign prostate hyperplasia and was admitted to the hospital earlier today with lower abdominal discomfort and difficulty voiding. Evaluation revealed a distended urinary bladder and serum creatinine of 1.3 mg/dL. A urinary catheter was placed, draining 400 mL of cloudy urine. He was started on empiric antibiotics and an alpha-adrenergic antagonist. Abdominal ultrasonography revealed no hydronephrosis, but 2 large gallstones were seen with no gallbladder wall thickening or dilation of the common bile duct. The patient has had intermittent abdominal bloating and mild nausea in the past but reports no fever, chills, pain in the right upper quadrant, or jaundice. Other medical problems include hypertension and type 2 diabetes mellitus.
Temperature is 36.6 C (98 F) , blood pressure is 144/83 mm Hg, and pulse is 78/min. BMI is 44 kg/m². Physical examination reveals mild suprapubic and epigastric tenderness on deep palpation, which does not accentuate on inspiration. There is no rebound tenderness.
Laboratory results are as follows:

Which of the following is the best next step in management of this patient's gallstones?

Quizplus · Accepted Answer

11ec193a_96c8_7589_853d_b7c9a6554a5c_MD0002_00 Gallstones are commonly found incidentally during evaluation of patients with abdominal pain due to other causes. Risk factors for gallstones include obesity, female sex, age >40, hemolytic anemias, pregnancy, certain medications (eg, oral contraceptives), and hypertriglyceridemia. Asymptomatic gallstones are associated with a low risk of future complications and do not require intervention, whereas symptomatic gallstones require cholecystectomy. Therefore, management depends on differentiating biliary from nonbiliary sources of abdominal pain. Typical features of symptomatic gallstones include biliary colic (eg, episodic pain in the right upper quadrant, radiation to the back and right shoulder, symptoms with fatty foods), acute cholecystitis (eg, prolonged pain in the right upper quadrant, fever, leukocytosis), elevated hepatobiliary markers (eg, hepatic transaminases, bilirubin), or jaundice. Atypical symptoms (eg, indigestion, belching, bloating, pain in other areas of the abdomen) are less likely to indicate gallstones. Typical features of symptomatic gallstones include biliary colic (eg, episodic pain in the right upper quadrant, radiation to the back and right shoulder, symptoms with fatty foods), acute cholecystitis (eg, prolonged pain in the right upper quadrant, fever, leukocytosis), elevated hepatobiliary markers (eg, hepatic transaminases, bilirubin), or jaundice. Atypical symptoms (eg, indigestion, belching, bloating, pain in other areas of the abdomen) are less likely to indicate gallstones. This patient does not have typical gallstone symptoms and, therefore, does not require further workup or treatment of his gallstones (Choice C). Management should be directed at the underlying cause of pain (eg, bladder outflow obstruction, possible urinary tract infection). (Choice A) An empiric trial of ursodeoxycholic acid to dissolve gallstones may be considered in patients with atypical symptoms if other causes are ruled out, as it can predict symptom improvement with cholecystectomy. Urosodeoxycholic acid is most effective in patients with small, cholesterol-rich stones and requires prolonged therapy (years); the failure rate is high. (Choice B) MR cholangiography is used to evaluate the hepatic bile ducts and pancreatic duct; it can help diagnose common bile duct stones, malignant duct obstructions, and obliterative diseases. However, these diseases are expected to cause elevations in liver function tests (not seen in this patient). (Choice D) Hepatobiliary cholescintigraphy (HIDA scan) is useful to evaluate for patency of the cystic duct, common bile duct, and ampulla and can help diagnose cholecystitis in patients with biliary colic but inconclusive ultrasonography. This patient's visualized stones and lack of biliary colic make this test unnecessary. Educational objective: Incidental gallstones are a common finding in patients with abdominal pain but do not require treatment if they are not the cause of the symptoms. Patients with incidental gallstones who present with atypical features (lack of biliary colic) should be evaluated for other causes of pain. __________ References: Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy. (http://www.ncbi.nlm.nih.gov/pubmed/17390223)

A 78-Year-Old Man Is Evaluated for Gallstones