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Gallstone disease

About

What is covered

This pathway covers the diagnosis and management of gallstone disease in adults.
Gallstone disease occurs when hard fatty or mineral deposits (gallstones) form in the gallbladder. Approximately 15% of the adult population are thought to have gallstone disease, and most of these people experience no symptoms. For a small proportion of people with gallstone disease, the stones irritate the gallbladder or block part of the biliary system, and this can cause symptoms such as pain, infection and inflammation. If these symptoms are left untreated, gallstones can cause more serious and in some cases life-threatening conditions such as cholecystitis, cholangitis, pancreatitis and jaundice.
There is variation in how gallstone disease is managed. Some people with symptomless gallstone disease are offered treatment to prevent symptoms developing in the future, whereas others are offered a watch-and-wait approach. When people experience symptoms of gallstone disease they often need surgery to remove their gallbladder. There is uncertainty about the best way of treating gallstone disease. In addition, if surgery is appropriate there is uncertainty about whether it should be performed as soon as possible after a gallstones attack or delayed until any infection and inflammation has subsided.

Updates

Updates to this pathway

2 December 2015 Gallstone disease (NICE quality standard 104) added to this pathway.
16 December 2014 Single-incision laparoscopic cholecystectomy (NICE interventional procedure guidance 508) added to this pathway.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Diagnosis and management of gallstone disease in adults

What is covered

This pathway covers the diagnosis and management of gallstone disease in adults.
Gallstone disease occurs when hard fatty or mineral deposits (gallstones) form in the gallbladder. Approximately 15% of the adult population are thought to have gallstone disease, and most of these people experience no symptoms. For a small proportion of people with gallstone disease, the stones irritate the gallbladder or block part of the biliary system, and this can cause symptoms such as pain, infection and inflammation. If these symptoms are left untreated, gallstones can cause more serious and in some cases life-threatening conditions such as cholecystitis, cholangitis, pancreatitis and jaundice.
There is variation in how gallstone disease is managed. Some people with symptomless gallstone disease are offered treatment to prevent symptoms developing in the future, whereas others are offered a watch-and-wait approach. When people experience symptoms of gallstone disease they often need surgery to remove their gallbladder. There is uncertainty about the best way of treating gallstone disease. In addition, if surgery is appropriate there is uncertainty about whether it should be performed as soon as possible after a gallstones attack or delayed until any infection and inflammation has subsided.

Updates

Updates to this pathway

2 December 2015 Gallstone disease (NICE quality standard 104) added to this pathway.
16 December 2014 Single-incision laparoscopic cholecystectomy (NICE interventional procedure guidance 508) added to this pathway.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Gallstone disease (2014) NICE guideline CG188
Single-incision laparoscopic cholecystectomy (2014) NICE interventional procedure guidance 508
Gallstone disease quality standard (2014) NICE quality standard 104

Quality standards

Gallstone diease

These quality statements are taken from the gallstone diease. The quality standard defines clinical best practice for the diagnosis and management of gallstone diease and should be read in full.

Quality statements

Acute cholecystitis

This quality statement is taken from the gallstone disease quality standard. The quality standard defines clinical best practice in gallstone disease and should be read in full.

Quality statement

Adults with acute cholecystitis have laparoscopic cholecystectomy within 1 week of diagnosis.

Rationale

The earlier a laparoscopic cholecystectomy is performed, the less potential there is for recurrent events such as inflammation and the infection spreading during the wait for surgery. If laparoscopic cholecystectomy cannot be performed within 1 week of diagnosis of acute cholecystitis, surgery should be delayed until the acute episode has subsided (more than 4 weeks after diagnosis).

Quality measures

Structure
a) Evidence of local arrangements to ensure that adults with acute cholecystitis have laparoscopic cholecystectomy within 1 week of diagnosis.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that secondary care services that offer laparoscopic cholecystectomy regularly perform the procedure.
Data source: Local data collection.
Process
Proportion of adults with acute cholecystitis who have a laparoscopic cholecystectomy within 1 week of diagnosis.
Numerator – the number in the denominator who have a laparoscopic cholecystectomy within 1 week of diagnosis.
Denominator – the number of adults with acute cholecystitis.
Data source: Local data collection.
Outcome
a) Acute readmission rates for adults with acute cholecystitis.
Data source: Local data collection. National data can be collected from the Health and Social Care Information Centre’s Hospital Episode Statistics.
b) Length of stay for adults with acute cholecystitis.
Data source: Local data collection. National data can be collected from the Health and Social Care Information Centre’s Hospital Episode Statistics.
c) Quality of life for adults with acute cholecystitis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as secondary care services) ensure that surgeons are trained to perform laparoscopic cholecystectomy, and that adults with acute cholecystitis can have the procedure within 1 week of diagnosis.
Healthcare professionals (such as upper gastrointestinal surgeons) are trained to perform laparoscopic cholecystectomy, and provide it to adults with acute cholecystitis within 1 week of diagnosis.
Commissioners (such as clinical commissioning groups) monitor services that offer laparoscopic cholecystectomy to ensure that they regularly perform it, and that adults with acute cholecystitis can have the procedure within 1 week of diagnosis.

What the quality statement means for patients and carers

Adults with acute cholecystitis (infection in the gallbladder) have keyhole surgery to remove their gallbladder (part of the digestive system) within 1 week of the infection being diagnosed, to reduce the risk of pain, swelling, and the infection spreading while waiting to have surgery.

Source guidance

  • Gallstone disease (2014) NICE guideline CG188, recommendation 1.2.4 (key priority for implementation).

Definitions of terms used in this quality statement

Diagnosing acute cholecystitis
Acute cholecystitis is diagnosed using abdominal ultrasound to confirm the presence of gallstones and signs of acute gallbladder pathology. [Expert opinion]
Laparoscopic cholecystectomy
Removal of the gallbladder through ‘keyhole’ surgery. It should be performed within 1 week of diagnosis of acute cholecystitis. If it cannot be performed within 1 week of diagnosis, surgery should be delayed until the acute episode has subsided (more than 4 weeks after diagnosis).
[Adapted from gallstone disease (NICE guideline CG188)]

Urgent endoscopic retrograde cholangiopancreatography within 72 hours

This quality statement is taken from the gallstone disease quality standard. The quality standard defines clinical best practice in gallstone disease and should be read in full.

Quality statement

Adults with common bile duct stones causing jaundice have endoscopic retrograde cholangiopancreatography within 72 hours of diagnosis.

Rationale

Endoscopic retrograde cholangiopancreatography can be used to treat common bile duct stones. Adults should have the procedure performed within 72 hours of diagnosis of common bile duct stones if these are causing jaundice, to prevent further complications such as cholangitis while waiting for treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with common bile duct stones causing jaundice have endoscopic retrograde cholangiopancreatography within 72 hours of diagnosis.
Data source: Local data collection.
Process
Proportion of adults with common bile duct stones causing jaundice who have endoscopic retrograde cholangiopancreatography within 72 hours of diagnosis.
Numerator – the number in the denominator who have endoscopic retrograde cholangiopancreatography within 72 hours of diagnosis.
Denominator – the number of adults with common bile duct stones causing jaundice.
Data source: Local data collection.
Outcome
Rates of cholangitis in adults with common bile duct stones.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as secondary care services) ensure that healthcare professionals are trained to perform endoscopic retrograde cholangiopancreatography, and that adults can have it within 72 hours of diagnosis of common bile duct stones, if these are causing jaundice.
Healthcare professionals (such as gastroenterologists, radiologists and upper gastrointestinal surgeons) are trained to perform endoscopic retrograde cholangiopancreatography, and provide it for adults within 72 hours of diagnosis of common bile duct stones, if these are causing jaundice.
Commissioners (such as clinical commissioning groups) monitor services that offer endoscopic retrograde cholangiopancreatography to ensure that they regularly perform it, and that adults can have this procedure within 72 hours of diagnosis of common bile duct stones, if these are causing jaundice.

What the quality statement means for patients and carers

Adults with common bile duct stones causing jaundice are able to have an endoscopy (inserting a thin, flexible tube down their throat to perform surgery inside their body) within 72 hours of getting their diagnosis. The endoscopy is to remove the stones in their bile duct (part of the digestive system that is connected to the gallbladder) and prevent other problems such as blockages, inflammation or infection.

Source guidance

Emergency endoscopic retrograde cholangiopancreatography within 24 hours

This quality statement is taken from the gallstone disease quality standard. The quality standard defines clinical best practice in gallstone disease and should be read in full.

Quality statement

Adults with common bile duct stones who need emergency endoscopic retrograde cholangiopancreatography have it within 24 hours.

Rationale

Endoscopic retrograde cholangiopancreatography can be used to treat common bile duct stones. Not everybody will need this procedure within 24 hours, but emergency endoscopic retrograde cholangiopancreatography can improve outcomes for adults with acute cholangitis or acute pancreatitis if their condition is not responding to antibiotics or intravenous fluids. Delaying endoscopic retrograde cholangiopancreatography for adults with these conditions risks complications such as sepsis.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with common bile duct stones who need emergency endoscopic retrograde cholangiopancreatography have it within 24 hours.
Data source: Local data collection.
Process
Proportion of adults with common bile duct stones who need emergency endoscopic retrograde cholangiopancreatography who have it within 24 hours.
Numerator – the number in the denominator who have endoscopic retrograde cholangiopancreatography within 24 hours.
Denominator – the number of adults with common bile duct stones who need emergency endoscopic retrograde cholangiopancreatography.
Data source: Local data collection.
Outcome
Rates of sepsis in adults with common bile duct stones.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as secondary care services) ensure that healthcare professionals are trained to perform endoscopic retrograde cholangiopancreatography, and that adults with common bile duct stones who need this procedure in an emergency can have it within 24 hours. For 24 hour endoscopic retrograde cholangiopancreatography, service providers may need to be aware of local networks.
Healthcare professionals (such as gastroenterologists, radiologists and upper gastrointestinal surgeons) are trained to perform endoscopic retrograde cholangiopancreatography, and provide it for adults with common bile duct stones who need it in an emergency within 24 hours.
Commissioners (such as clinical commissioning groups) monitor services that offer endoscopic retrograde cholangiopancreatography to ensure that they regularly perform it, and that adults with common bile duct stones can have it as an emergency within 24 hours if needed.

What the quality statement means for patients and carers

Adults with common bile duct stones are able to have an endoscopy (inserting a thin, flexible tube down their throat to perform surgery inside their body) within 24 hours if they need it in an emergency. The endoscopy is to remove the stones in their bile duct (part of the digestive system that is connected to the gallbladder) and prevent other problems such as blockages, inflammation or infection.

Source guidance

Definitions of terms used in this quality statement

Emergency endoscopic retrograde cholangiopancreatography
Emergency endoscopic retrograde cholangiopancreatography (within 24 hours) is needed for adults with common bile duct stones and acute cholangitis or acute pancreatitis when indicated.
[Adapted from gallstone disease (NICE guideline CG188) recommendations 1.3.1 and 1.3.2, and Royal College of Surgeons (2013) Commissioning guide: gallstone disease, section 1.2 and expert consensus]

Advice to prevent symptoms

This quality statement is taken from the gallstone disease quality standard. The quality standard defines clinical best practice in gallstone disease and should be read in full.

Quality statement

Adults with symptomatic gallstone disease who have not had their gallbladder or gallstones removed are advised to avoid food and drink that triggers their symptoms.

Rationale

Certain food and drink may trigger symptoms of gallstone disease, such as pain and discomfort. Adults with gallstone disease should be advised to avoid food and drink that triggers their symptoms while they are waiting for treatment. In addition, some adults may be not be able to have treatment (for example because they are unwell), and should be given dietary advice to reflect this.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults with symptomatic gallstone disease who have not had their gallbladder or gallstones removed are advised to avoid food and drink that triggers their symptoms.
Data source: Local data collection.
Process
Proportion of adults with symptomatic gallstone disease who have not had their gallbladder or gallstones removed who are advised to avoid food and drink that triggers their symptoms.
Numerator – the number in the denominator who are advised to avoid food and drink that triggers their symptoms.
Denominator – the number of adults with symptomatic gallstone disease who have not had their gallbladder or gallstones removed.
Data source: Local data collection.
Outcome
a) Patient experience.
Data source: Local data collection.
b) Quality of life for adults with gallstone disease.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as primary and secondary care services) ensure that systems are in place for adults with symptomatic gallstone disease who have not had their gallbladder or gallstones removed to be advised to avoid food and drink that triggers their symptoms.
Healthcare professionals (such as GPs and gastroenterologists) advise adults with symptomatic gallstone disease who have not had their gallbladder or gallstones removed to avoid food and drink that triggers their symptoms. Healthcare professionals should document the advice that is given.
Commissioners (such as NHS England area teams and clinical commissioning groups) ensure that they commission services that make sure adults with symptomatic gallstone disease who have not had their gallbladder or gallstones removed are advised to avoid food and drink that triggers their symptoms.

What the quality statement means for patients and carers

Adults with symptomatic gallstone disease who have not had their gallbladder or gallstones removed are advised by their healthcare professional to avoid any food or drink that triggers their symptoms.

Source guidance

Definitions of terms used in this quality statement

Advice
Any advice given by a healthcare professional should include both oral and written information.
[Patient experience in adult NHS services (NICE guideline CG138) recommendation 1.5.12]

Equality and diversity considerations

Advice about gallstone disease should take into account any additional needs, such as physical, sensory or learning disabilities, and adults who do not speak English. Adults should have access to an interpreter or advocate if needed.
Healthcare professionals should also be aware that certain cultural groups may be more likely to eat food and drink that may trigger symptoms of gallstone disease. People who are homeless may also be less able to avoid certain food and drink.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

Stones that are found incidentally, as a result of imaging investigations unrelated to gallstone disease in people who have been completely symptom free for at least 12 months before diagnosis.
Stones that are found incidentally, as a result of imaging investigations unrelated to gallstone disease in people who have been completely symptom free for at least 12 months before diagnosis.
Build-up of pus in the gallbladder, as a result of a blocked cystic duct.
Removal of the gallbladder through 'keyhole' surgery.
A procedure to drain pus and fluid from an infected gallbladder.
Stones found on gallbladder imaging, regardless of whether symptoms are being experienced currently or whether they occurred sometime in the 12 months before diagnosis.
Stones found on gallbladder imaging, regardless of whether symptoms are being experienced currently or whether they occurred sometime in the 12 months before diagnosis.

Paths in this pathway

Pathway created: October 2014 Last updated: December 2015

© NICE 2017

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