Estudiante

Management of Gallstones
CHArlES F. BElloWS, M.D., and DAvID H. BErGEr, M.D., Baylor College of Medicine, Houston, Texas rICHArD A. CrASS, M.D., University of Florida Health Science Center, Jacksonville, Florida

Many patients with gallstones can be managed expectantly. Generally, only persons with symptoms related to the presence of gallstones (e.g., steady, nonparoxysmal pain lasting four tosix hours located in the upper abdomen) or complications (such as acute cholecystitis or gallstone pancreatitis) warrant surgical intervention. Biliary pain is alleviated by cholecystectomy in the majority of cases. Laparoscopic cholecystectomy is considered the most cost-effective management strategy in the treatment of symptomatic gallstones. Medical management strategies are mostly palliativeand are not widely supported. Patients with longer-lasting biliary pain, in combination with abdominal tenderness, fever, and/or leukocytosis, require an ultrasound evaluation to help establish a diagnosis of acute cholecystitis. Once a patient is diagnosed, having cholecystectomy early in the course of the disease can significantly reduce the hospital stay. (Am Fam Physician 2005;72:637-42.Copyright© 2005 American Academy of Family Physicians.)

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Table 1

allstone disease affects 12 percent of the population in the United States. Several factors are associated with an increased occurrence of gallstone formation (Table 1). In a multivariate analysis1 of more than 900 patients, researchers identified a family history of cholecystectomy in a first-degree relative and obesity (definedas body mass index [BMI] greater than 30 kg per m2) as strong risk factors for symptomatic gallstone disease with a relative risk of 2.2 (95% confidence interval [CI], 1.5 to 3.0) and 3.7 (95% CI, 2.3 to 5.3), respectively. Weight loss patterns also are associated with symptomatic gallstones. Weight loss

Risk Factors Associated with Increased Occurrence   of Gallstones
Body habitus: obesity,*rapid weight loss, cyclic weight loss Childbearing Drugs: ceftriaxone (Rocephin), postmenopausal estrogens, total parenteral nutrition Ethnicity: Native American (Pima Indian), Scandinavian Female gender Heredity: first-degree relatives Ileal disease, resection, or bypass Increasing age
*—Obesity defined as body mass index greater than 30 kg per m2.

of more than 1.5 kg (3.3 lb) per week hasbeen associated with a higher rate of gallstone formation compared with rates of less than 1.5 kg per week.2 In a large cohort3 of middle-aged women, one or more cycles of weight loss and gain of 9 kg (20 lb) or more was a strong risk factor for cholecystectomy independent of BMI, with a relative risk approaching 2.0 (95% CI, 1.3 to 2.1). Interestingly, epidemiologic evidence suggests that increasedphysical activity is associated inversely with the risk of gallstone formation. In a prospective cohort study,4 symptomatic gallstone disease in men was reduced by approximately 20 percent in those who increased their physical activity by 25 metabolic equivalents per week (i.e., at least 30 minutes per day five times a week). In the United States, cholesterol stones are the most common type ofgallstone, with pigmented stones occurring less often. The formation of cholesterol stones is a result of cholesterol supersaturation, accelerated cholesterol crystal nucleation, and impaired gallbladder motility. The majority of asymptomatic patients with gallstones will remain asymptomatic for many years. According to a 1992 National Institutes of Health consensus conference on gallstones,5 10percent of patients with gallstones will develop symptoms in the first five years after diagnosis. In 1995, the Group for Epidemiology and Prevention of Cholelithiasis reported that

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