The Diagnosis and Management of Gallstones in the Elderly
Bao Q. Tang, MD, FRCS(C), Clinical Fellow, Minimally Invasive Surgery Program, Division of General Surgery, University Health Network, Toronto, ON.
David R. Urbach, MD, MSc, FRCS(C), Assistant Professor of Surgery and Health Policy, Management and Evaluation, University of Toronto; Staff Surgeon, Division of General Surgery, University Health Network, Toronto, ON.
Gallstone disease is common in elderly persons. The clinical syndromes caused by symptomatic gallstones include biliary colic, acute cholecystitis, acute gallstone pancreatitis, choledocholithiasis, cholangitis and gallstone ileus. In most cases, an accurate diagnosis can be made on the basis of the history, physical examination, basic blood tests and abdominal ultrasonography. Cholecystectomy is the appropriate treatment for most patients with symptomatic gallstones, and can be done safely in the elderly. Because the risk of complications of gallstone diseases is higher in the elderly than in younger patients, symptomatic gallstone disease should be identified and treated promptly in elderly persons.
Key words: gallstones, cholecystitis, pancreatitis, cholangitis, cholecystectomy.
Introduction
Gallstone disease is common in developed countries, occurring in 10-20% of the population, and in approximately one-third of those older than 70 years.1 Although many individuals with gallstones do not have any symptoms and require no treatment, those patients with symptoms suggestive of gallstone disease should be investigated and subsequently treated if gallstones are present.
Compared with the management of symptomatic gallstone disease in young patients, management in the elderly is guided by three important considerations. First, elderly patients are more likely to present with complications than younger patients with symptomatic gallstones.2 Second, some elderly patients with severe, life-threatening complications of gallbladder disease may present with very mild signs and symptoms. Third, although the morbidity and mortality of elective gallbladder surgery in elderly patients is similar to those in younger patients, the mortality of emergency surgery is much higher among the elderly.3 As a result, symptomatic gallstone disease should be identified and treated promptly in the elderly. Fortunately, recent advances in therapeutic endoscopy and surgery have made effective treatment of symptomatic gallstones much safer than in the past.
Gallbladder Disease
Bile is a substance that facilitates the intestinal absorption of lipids and fat-soluble vitamins, and is secreted by the liver into the bile duct. The gallbladder stores bile during the fasting state, and empties it into the small intestine following ingestion of a fatty meal. Contraction of the gallbladder forces bile into the common bile duct, from where it passes through the sphincter of Oddi into the duodenum. The gallbladder is joined to the bile duct by the cystic duct (Figure 1a). The flow of bile between the liver, gallbladder and duodenum is under neurohormonal control. The most common types of gallstones that develop in North American patients are cholesterol gallstones, the formation of which appears to be a phenomenon of the "Western" lifestyle and is related to the supersaturation of cholesterol in bile. Less common types of gallstones include "black" or "brown" stones resulting from hematologic disorders with hemolysis, cirrhosis and chronic infection of the biliary tract.
In many patients, gallstones are an incidental finding on an abdominal ultrasound. If there has been no previous history of symptoms suggestive of gallbladder disease, these patients are said to have asymptomatic gallstones. In general, patients with asymptomatic gallstones do not require treatment.4 Clinically overt gallbladder disease can take the form of one of several clinical syndromes: (1) biliary colic; (2) acute cholecystitis; (3) acute gallstone pancreatitis; (4) choledocholithiasis (common bile duct stones); and (5) acute cholangitis (Figure 1b). Although it is a rare condition, we also include a discussion of gallstone ileus in this article