Good question for a common problem.Even in a developing country like India Gallstone incidence has increased during last three decades contrary to what i I thought while returning from UK.Undoubtedly u/s has contributed for the detection.Life style of people has changed including the life style diseases.This has undoubtedly contributed for the increased incidence.Lap chole is very well accepted by those with major comorbities as well.Significant number are treated in our country are in private sector they have to pay , one way or other.On the other hand awareness has very much increased. When I look in to my own  large series in these three decades,I donot think that we are over treating .sorry I dont have statistics to support,those who were not keen to get operated have come come back with major complications making a simple proceedure a complicated one.

Dear Dr Nehra 

In my experience as a pediatric hepatogastroenterologist, the answer is certainly yes. Most of gall stones in pediatric age are asymptomatic and can spontaneously recover on follow up. Either they are discovered incidentally due to ultrasonogaphic assessment for any reason or due to RAP. Moreover, many gall stone diseases are transient due to some drugs like ceftriaxone.

If by overtreatment you mean operating asymptomatic gallstone, then in doing so one has to consider other local facts also e.g. in India incidence of GB cancer is high (most present in late stages) and  90% are associated with gallstone so one feels prudent to operate early. But symptomatic gallstones should definitely be operated as complications are high.

Of course  there is over treating of the asymptomatic GB stones as regard medical ttt , it is very difficult for the patient not to receive medical ttt when he discover the diagnosis, Also there is controversy about the operative interference in asymptomatic GB stone.

In my opinion, the problem is solved since years.

Asymptomatic GB stones are never an indication.

For GB stones, acute infection and typical pain : dull, progressive, isolated, epigastric ache, during approximatively 3 hours warrant cholecystectomy. As it isn't an emergency, it's possible to wait for an other bout before surgery. Suspicion of associated cancer is a rare but indisputable indication.

For CBD stones, the problem is different. Surgery (laparoscopic or ERCP) is mandatory if symptomatic. If not with normal biology or very bad health, abstention is to be considered..

Therein lies the problem; to determine which gallstone is 'troublesome' given that there is so much overlap in symptoms especially in women

There is no overlap when using precise semeiology.

Biliary pain is most frequently typical and easy to differentiate of functional pain. Even if symptoms are atypical, their occurrence as clearly separate bouts helps to spot them.

Moreover, a precise semeiology of functional pain and tracking causative, associated depression (sleep, fatigue, dynamism …), allows a positive diagnosis. Except in case of fortuitous association, they miss in case of biliary pain.

I am afraid your suggestion of 'precise semeiology ' is not bourne by the exponential rise in laparoscopic cholecystectomy worldwide. 

I agree with you.

Precise analysis of questioning is now out-dated, although basis of diagnosis. It remains, however, the only mean for ascribing the pain to biliary tract.

This is one of the dark sides of changing in medicine.

A good question! I think this question need to be studied based on a massive clinical data.

If The finding of gallstone is incidental then as your data suggest I would give the patient the option filling him/ her fully in on complications of lap cholecystectomy and discuss risk benefit and this setting. If, however, the gallstones are symptomatic I would suggest operating. It is also prudent to exclude other pathology first and if symptoms don't fit I would investigate further before surgery pointing out that there is a chance that  atypical symptoms might persist or even worsen.

Whilst I agree with all the comments I question the trend. In atypical cases it can be difficult to convince pt that there symptoms are not due to the incidental gallstones and other tests are usually normal especially with up to 30% of pts having functional GI disorders. And there is the problem of medical fraternity who tend to overtreat  perhaps due to misc incentives. 

I agree. Asymptomatic gallstones can clearly be managed conservatively but in patients with equivocal symptoms there may be considerable overlap with other functional disorders some of which may be made worse (IBS) by cholecystectomy

Andrew,what conservative management do you offer ? As mentioned by our co researcher,how will we explain if he/she develops a cancer.I do realise it is not common in your country.I see on an average at least two patients monthly with disseminated disease.

Prasanna

gallbladder cancer has a similarity to pancreatic cancer . It is usually too advanced as you mentioned to treat when diagnosed. The question Is specific for gallstones in the absence of suspicion of ca on scans .

Dhiren,You mean doing a CT or MRI or CA19-9 for all those patients coming with Gall stones ? which i feel that it is too much even in a setup where i am working.I beg to differ GB cancer has not many similarities like pancreatic cancer

You are right. GB cancers are relatively rare, whereas gallstones are extremely common. I was only really referring to gallstone patients without significant symptoms. As long as the possibility of complications related to their stones are discussed many patients can avoid surgery. Clearly if there are symptoms, any concerns on the scan or other complications (jaundice etc) then surgery is indicated

very small stones or gravels are always associated with complications especially acute pancreatitis or recurrent cholangitis so it is better to operated early