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Clinical Guidelines
Are the authors1 aware of any clinical guidelines from the American Academy of Family Physicians or other groups recommending monitoring asymptomatic patients with gallstones?
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Ten to 15% of the population in Western industrialized nations will develop gallstones and 500,000 cholecystectomies are performed each year in the United States.2 Gallstones exist in 3 clinical stages: asymptomatic, symptomatic, and complicated. Ideally, all patients will be treated before their condition becomes complicated. Fortunately, almost all patients with gallstones have symptoms before they develop complications; therefore, expectant treatment during the asymptomatic stage is usually safe. As a result, most groups reviewing asymptomatic patients with gallstones in the last 20 years have reached a similar conclusion, ie, that asymptomatic patients should not undergo surgery until or unless symptoms develop. The guideline, therefore, is simple: observe, understanding that 1% will become symptomatic each year. The availability of laparoscopic surgery has not altered this recommendation. Patients who have unrelated gastrointestinal complaints such as irritable bowel disease, dyspepsia, ulcer disease, or hiatal hernias present a clinical challenge. Ultrasound availability has increased the likelihood that gallstones will be discovered before patients become symptomatic. Patients with diabetes deserve special attention because they move from the symptomatic stage to the complicated stage faster than the general population. Several articles are available that contain consensus guidelines from respected panels.2-4
A good review for patients is available at http://www.niddk.nih.gov/health/digest/pubs/gallstns/gallstns.htm from the National Digestive Diseases Information Clearinghouse, Bethesda, Md.
Thomas C. Rosenthal, MD
Buffalo, NY
1. Zubler J, Markowski G, Yale S, Graham R, Rosenthal T. Natural history of asymptomatic gallstones in family practice office practices. Arch Fam Med. 1998;7:230-233.
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2. Strasberg SM, Clavien PA. Overview of therapeutic modalities for the treatment of gallstone diseases. Am J Surg. 1993;165:420-426.
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3. American College of Physicians. Guidelines for the treatment of gallstones. Ann Intern Med. 1993;119:620-622.
4. Ransohoff DF, Gracie WA. Treatment of gallstones. Ann Intern Med. 1993;119:606-619.
Arch Fam Med. 1999;8:197-198.
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