MKSAP: 41-year-old woman with burning epigastric and chest pain

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 41-year-old woman is evaluated in follow-up after presenting to the emergency department 1 week ago for burning epigastric and chest pain. In the emergency department, a complete blood count and liver chemistry studies were normal, but a radiograph of the chest and upper abdomen demonstrated calcified gallstones. The pain resolved with administration of a liquid antacid, and omeprazole was started. The pain had been present intermittently for approximately 6 months prior to the emergency department visit. It occurred nearly every day, usually after meals and when recumbent, and had been typically burning in nature at night. The pain has not recurred since she started omeprazole. She has not had dysphagia and has a good appetite and stable weight. Her medical history is notable for obesity.

On physical examination, vital signs are normal; BMI is 36. There is no abdominal tenderness, and the liver and spleen are of normal size. Murphy sign is negative.

Which of the following is the most appropriate management for this patient’s gallstones?

A. Annual ultrasonography
B. Laparoscopic cholecystectomy
C. Ursodiol
D. Clinical observation

MKSAP Answer and Critique

The correct answer is D. Clinical observation.

The most appropriate management for this patient’s gallstones is clinical observation. Her symptoms are consistent with gastroesophageal reflux. Gallstones were incidentally found on her evaluation but are asymptomatic. Biliary colic is the most common clinical presentation in patients with symptomatic gallstones. The usual presentation of biliary colic is episodic, severe abdominal pain typically in the epigastrium and/or right upper quadrant but occasionally in the right lower or mid-abdomen. The pain rapidly intensifies over a 15-minute interval to a steady plateau that lasts as long as 3 hours and resolves slowly. The pain is often associated with nausea or vomiting, and there is no jaundice. Pain may radiate to the interscapular region or right shoulder. An estimated 60% to 80% of gallstones are asymptomatic. Over a 20-year period, 50% of patients remain asymptomatic, 30% have biliary colic, and 20% have more serious complications. Observation is recommended for adult patients with asymptomatic gallstones. The possible exceptions to this recommendation are groups at higher risk for gallbladder carcinoma, such as patients with a calcified (porcelain) gallbladder, certain American Indians, and patients with gallstones larger than 3 cm.

Risks for symptoms or complications from silent gallstones are about 2% per year and cumulative, and risks for complications in the absence of antecedent pain are minimal. Therefore, annual ultrasonography is unlikely to alter management decisions for this patient and she can be treated expectantly, based on the occurrence of symptoms.

Laparoscopic cholecystectomy is the treatment of choice for symptomatic biliary colic and acute cholecystitis. Mortality rates following laparoscopic cholecystectomy are less than 0.7%, and complication rates (including bile duct injuries) do not differ between laparoscopic and open cholecystectomy. However, this patient’s pain is inconsistent with biliary pain, and neither laparoscopic nor open cholecystectomy is indicated.

Oral administration of ursodiol for dissolution of gallstones is rarely used. It can be considered in patients with symptomatic noncalcified gallbladder stones who are at high risk for cholecystectomy.

Key Point

  • Observation is recommended for adult patients with asymptomatic gallstones.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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