Managing Gallstone Disease in the Elderly

Key points

Asymptomatic cholelithiasis

Gallstones are asymptomatic in most individuals and incidentally diagnosed through imaging. A recent study by Shabanzadeh and colleagues¹¹ included 664 patients with gallstones with a median age of 60 years, among whom 19.6% of participants developed gallstone-related events (8.0% complicated and 11.6% uncomplicated). The study showed a negative association between age and gallstone-related events. Similar trends have been observed in prior cohort studies.^12,13

Biliary colic

Gallbladder contraction against the cystic duct opening may cause right upper quadrant or epigastric pain of variable severity, associated with postprandial exacerbations and nocturnal variations.19, 20, 21 Elderly patients may present with altered mental status, falls, or incontinence.²²

Among symptomatic patients, gallstones are commonly diagnosed through ultrasonography (US) and appear as acoustic shadows (Fig. 2A, B). Biliary sludge observed on US may indicate microlithiasis and has resulted

Acute cholecystitis

Acute cholecystitis refers to acute inflammation of the gallbladder, which in most cases results from gallstones, except among 5% to 10% of patients with acalculous cholecystitis. Acute calculous cholecystitis results from cystic duct obstruction and increased intraluminal pressure and congestion. In addition, lysolecithin, an enzyme arising from mucosal irritation by gallstones, causes gallbladder inflammation.^31,32 Superimposed infections may also contribute, as shown among patients with

Chronic cholecystitis

Long-standing gallstones or prior episodes of acute cholecystitis may cause indolent gallbladder inflammation, also called chronic cholecystitis. On histology, gallbladder wall thickening, serosal adhesions, smooth muscle hypertrophy, and pathognomonic Rokitansky-Aschoff sinuses are observed.⁸⁶ The chronic inflammation may cause gallbladder calcification and porcelain gallbladder, the mechanism of which is unclear.⁸⁷

Choledocholithiasis

Choledocholithiasis refers to the presence of gallstones in the CBD. Although associated with up to 5% to 20% of patients with gallstones, the exact incidence and prevalence of choledocholithiasis is unknown.⁹⁰ Among the elderly, most calculi originate from the gallbladder and migrate into the CBD.⁹¹ Alternatively, primary choledocholithiasis may result from long-standing biliary stasis associated with conditions including CBD dilatation and periampullary diverticulum (PAD).⁹²

Role for sphincterotomy among nonsurgical candidates

Age and comorbidities may render geriatric individuals with ABP unsuitable for cholecystectomy and subsequently cause recurrent biliary events. Endoscopic sphincterotomy (ES) has been used for prophylaxis among these patients and mitigates the risk of recurrent ABP, biliary events, readmissions, and mortality.^135,136 A recent study showed the protective role of ES for ABP recurrence (adjusted hazard ratio [HR], 0.29; 95% CI, 0.08–0.92; P = .037) and any gallstone-related event (HR, 0.46; 95%

Summary

With advanced age demographics, gallstone disease and associated complications are projected to have a much higher prevalence. Current advancements in diagnostic and therapeutic modalities have enabled inclusion of geriatric individuals for biliary interventions. However, each procedure needs appraisal for efficacy, therapeutic targets, safety, and cost-effectiveness. With risk/benefit ratio in mind, formulation of an individualized treatment plan with a multidisciplinary approach is

Clinics care points

• •

  Among the geriatric population with acute cholecystitis, symptoms are atypical and physical signs may be masked by neuropathy. For e.g. Murphy sign has a lower sensitivity of 48% among the elderly. Typical leukocytosis and bandemia may be also obscured. Diagnostic sensitivity and specificity of acute cholecystitis was found to be 88% and 80% respectively.²⁴Patients with acute cholecystitis warrant risk stratification followed by definitive drainage. Cholecystectomy is preferred treatment and

Acknowledgments

The authors would like to thank Mr Todd-Allen Lane, Chief, Library & Multimedia Services, Bridgeport Hospital for his help in literature search and multimedia services.