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Gallstones – Information for GPs

Referral criteria / commissioning position

Refer to secondary care for:

Suspected biliary colic if:

  • primary care management fails to resolve the symptoms
  • multiple attacks experienced
  • the patient would consider surgery

Suspected acute cholecystitis, choledochlithiasis or ascending cholangitis:

  • admit to secondary care

Incidental Gallstones seen on a scan:

  • Discuss with the patient need for referral depending on age, USS findings and the presence of any symptoms. Assymptomatic Gallstones do not necessarily need removal.

Red flag symptoms

  • Painless jaundice is unlikely to be gallstone related and signifies a head of pancreas tumour until proven otherwise
  • Couvoisier’s sign (or law) describes a palpable gallbladder/mass in the RUQ of patients with obstructive jaundice and is caused by tumors of the biliary tree or pancreatic head. The onset of jaundice is slow and progressive. The obstruction causes the gall bladder to dilate. The wall of the gall bladder is thin. This is in contrast gall stone disease, where the gallstones cause a fibroepithelial thickening of the gall bladder wall. Couvoisier’s sign is thus negative in gall stone disease because the gall bladder is reduced in size by the fibrotic reaction.

Risk factors

  • The 4 F’s – “Fat, fertile, female and family history”
  • Age > 60
  • Oestrogen – causes excess excretion of cholesterol in bile
  • High fibre diet
  • Pregnancy – oestrogen related
  • Rapid weight loss (e.g. after bariatric surgery)
  • Statins
  • Loss of bile salts (terminal ileitis or after terminal ileal resection)
  • Diabetes – via metabolic syndrome

Investigations prior to referral

FBC, U&Es, LFTs, biliary USS

Information to include in referral letter

  • Description of number of episodes and severity
  • LFTs, inflammatory markers and USS scan report including any evidence of CBD dilatation
  • Willingness of the patient to under-go major abdominal surgery
  • Relevant past medical/surgical history
  • Drug history (prescribed and non-prescribed)
  • Current regular medication
  • BMI
  • Smoking status
  • Alcohol consumption

Patient leaflets

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