Ease Into Prep with a PANCE^® Question of the Day

The correct answer is C. This patient has asymptomatic gallstones that were incidentally found. Gallstones are frequently asymptomatic and when found do not require any further intervention or workup. There is some evidence that a low-carbohydrate diet together with increased physical activity may help prevent gallstone formation. In our patient, lifestyle modification would be useful mainly to prevent the sequelae of obesity. Rapid weight loss should be discouraged in patients who have gallstones, because it may actually increase the risk for further gallstone formation caused by the biliary sludging that might occur in the setting of a patient eating fewer fat calories.

Laparoscopic cholecystectomy (choice A) is the treatment of choice in patients who have symptomatic gallstones, porcelain gallbladder, chronic cholecystitis, and acute cholecystitis or cholangitis. It is also indicated in patients who have asymptomatic gallstones and sickle cell disease or for people who are traveling to remote areas of the world who lack appropriate medical care if their condition becomes symptomatic. Because our patient has no symptoms from her incidentally discovered gallstones, treatment is unnecessary.

Endoscopic sphincterotomy (choice B) is the recommended treatment for choledocholithiasis. In this condition symptoms can be variable, but imaging reveals dilated gallbladder ducts. Antibiotics are necessary in this condition, because patients may progress to ascending cholangitis.

Right upper quadrant ultrasound (choice D) is the first test ordered in the workup of gallbladder disease, but our patient has already been adequately imaged with her CT scan. As long as she remains asymptomatic, no further imaging is necessary.

Treatment with ursodeoxycholic acid (choice E) is reserved for patients who refuse surgery or who are at too high a risk for surgery. This medication might help dissolve gallstones in those patients when taken for prolonged periods. Gallstones tend to recur whenever this medication is stopped. This is not a suitable alternative for surgery in patients who have symptomatic disease. Again, our patient does not need any intervention at this time.

PEARL: Asymptomatic gallstones discovered incidentally in an otherwise healthy patient require no intervention. Weight loss is indicated to prevent complications associated with obesity.

An exception is those who have asymptomatic gallstones and coexisting sickle cell disease who will require elective cholecystectomy. Patients with sickle cell disease tend to have chronic hemolysis, which leads to the formation of gallstones. Because this is a lifetime disease, those who have sickle cell disease (not just the trait) are encouraged to undergo elective cholecystectomy whenever gallstones are identified. Patients with sickle cell disease develop gallstones as a result of the chronic hemolysis that occurs.