Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about 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.

1.1 Diagnosing gallstone disease

1.1.1

Offer liver function tests and ultrasound to people with suspected gallstone disease, and to people with abdominal or gastrointestinal symptoms that have been unresponsive to previous management.

1.1.2

Consider magnetic resonance cholangiopancreatography (MRCP) if ultrasound has not detected common bile duct stones but the:

  • bile duct is dilated and/or

  • liver function test results are abnormal.

1.1.3

Consider endoscopic ultrasound (EUS) if MRCP does not allow a diagnosis to be made.

1.1.4

Refer people for further investigations if conditions other than gallstone disease are suspected.

1.2 Managing gallbladder stones

1.2.1

Reassure people with asymptomatic gallbladder stones found in a normal gallbladder and normal biliary tree that they do not need treatment unless they develop symptoms.

1.2.3

Offer day‑case laparoscopic cholecystectomy for people having it as an elective planned procedure, unless their circumstances or clinical condition make an inpatient stay necessary.

1.2.4

Offer early laparoscopic cholecystectomy (to be carried out within 1 week of diagnosis) to people with acute cholecystitis.

1.2.5

Offer percutaneous cholecystostomy to manage gallbladder empyema when:

  • surgery is contraindicated at presentation and

  • conservative management is unsuccessful.

1.3 Managing common bile duct stones

1.3.1

Offer bile duct clearance and laparoscopic cholecystectomy to people with symptomatic or asymptomatic common bile duct stones.

1.3.2

Clear the bile duct:

  • surgically at the time of laparoscopic cholecystectomy or

  • with endoscopic retrograde cholangiopancreatography (ERCP) before or at the time of laparoscopic cholecystectomy.

1.3.3

If the bile duct cannot be cleared with ERCP, use biliary stenting to achieve biliary drainage only as a temporary measure until definitive endoscopic or surgical clearance.

1.3.4

Use the lowest‑cost option suitable for the clinical situation when choosing between day‑case and inpatient procedures for elective ERCP.

1.4 Patient, family member and carer information

1.4.1

Advise people to avoid food and drink that triggers their symptoms until they have their gallbladder or gallstones removed.

1.4.2

Advise people that they should not need to avoid food and drink that triggered their symptoms after they have their gallbladder or gallstones removed.

1.4.3

Advise people to seek further advice from their GP if eating or drinking triggers existing symptoms or causes new symptoms to develop after they have recovered from having their gallbladder or gallstones removed.

Terms used in this guideline

Asymptomatic gallstones/ asymptomatic common bile duct stones

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.

Gallbladder empyema

Build‑up of pus in the gallbladder, as a result of a blocked cystic duct.

Laparoscopic cholecystectomy

Removal of the gallbladder through 'keyhole' surgery.

Percutaneous cholecystostomy

A procedure to drain pus and fluid from an infected gallbladder.

Symptomatic gallstones/ symptomatic common bile duct stones

Stones found on gallbladder imaging, regardless of whether symptoms are being experienced currently or whether they occurred sometime in the 12 months before diagnosis.