A 48-year-old woman comes to the emergency department due to sudden-onset right flank pain for 6 hours. She has never had abdominal pain before. Her only other medical problem is psoriasis at both knees, for which she uses topical vitamin D and beclomethasone. Vital signs are normal. The abdomen is soft with no tenderness. Bowel sounds are present. Abdominal imaging reveals a 3-mm stone in the right upper ureter and a few gallstones in the gallbladder. The liver and common bile duct are normal, the gallbladder is not distended, and there is no pericholecystic fluid or tenderness to ultrasound probe pressure. The patient is given analgesics and intravenous fluids; in a few hours she passes the ureteral stone in the urine with complete pain relief. Which of the following is the best next step in management of her gallstones?

Question

A 48-year-old woman comes to the emergency department due to sudden-onset right flank pain for 6 hours.  She has never had abdominal pain before.  Her only other medical problem is psoriasis at both knees, for which she uses topical vitamin D and beclomethasone.  Vital signs are normal.  The abdomen is soft with no tenderness.  Bowel sounds are present.  Abdominal imaging reveals a 3-mm stone in the right upper ureter and a few gallstones in the gallbladder.  The liver and common bile duct are normal, the gallbladder is not distended, and there is no pericholecystic fluid or tenderness to ultrasound probe pressure.  The patient is given analgesics and intravenous fluids; in a few hours she passes the ureteral stone in the urine with complete pain relief.  Which of the following is the best next step in management of her gallstones?

Quizplus · Accepted Answer

11ec25c8_d8f2_2fb0_bc81_238243c962f1_MD0003_00 This patient had acute symptoms due to a small kidney stone, which has now passed. However, she also had an incidental finding of asymptomatic gallstones. Only 20% of patients with asymptomatic gallstones will develop symptoms within 15 years. In light of this, no treatment is typically required for such patients. Exceptions to this rule include patients who are at increased risk for developing gallbladder carcinoma (eg, porcelain gallbladder). (Choices A and D) Laparoscopic cholecystectomy is often performed in patients with biliary colic (intermittent right upper quadrant pain) or acute cholecystitis. Open cholecystectomy is performed in patients who cannot tolerate a laparoscopic procedure or who have another intraabdominal process requiring surgery. Laparoscopic cholecystectomy (Choice B) Lithotripsy (laser or mechanical fragmentation) is sometimes used for gallstones in the bile duct that cannot be removed endoscopically. (Choice E) Oral ursodeoxycholic acid supplementation reduces symptoms from gallstones but does not lead to complete dissolution. It is used to treat symptomatic gallstones in individuals who are poor surgical candidates, but would be of no benefit for asymptomatic stones. Educational objective: Asymptomatic gallstones should not be treated. Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstone disease. 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) Surgical and nonsurgical management of gallstones. (http://www.ncbi.nlm.nih.gov/pubmed/24866215)

A 48-Year-Old Woman Comes to the Emergency Department Due to Sudden-Onset