BMJ 2014;349:g6241 doi: 10.1136/bmj.
g6241 (Published 30 October 2014)
Practice
GUIDELINE
Diagnosis and management of gallstone disease:
summary of NICE guidance
Sheryl Warttig technical analyst, Steven Ward technical analyst (health economics), Gabriel Rogers
technical adviser (health economics), On behalf of the Guideline Development Group
National Institute for Health and Care Excellence, Manchester M1 4BT, UK
This is one of a series of BMJ summaries of new guidelines based on
the best available evidence; they highlight important recommendations
for clinical practice, especially where uncertainty or controversy exists.
Gallstone disease is common10-15% of adults in Western
populations are thought to have the condition.1 2 Concerns about
inappropriate variation in the management of gallstones have
led to the development of recommendations on the diagnosis
and management of cholelithiasis, cholecystitis, and
choledocholithiasis in an attempt to improve patient outcomes
and promote effective use of resources. This article summarises
the most recent recommendations on the management of
gallstone disease from the National Institute for Health and Care
Excellence (NICE).3
Recommendations
NICE recommendations are based on systematic reviews of best
available evidence and explicit consideration of cost
effectiveness. When minimal evidence is available,
recommendations are based on the Guideline Development
Groups experience and opinion of what constitutes good
practice. Evidence levels for the recommendations are given in
italic in square brackets.
Diagnosis
Offer liver function tests and ultrasound to people with
suspected gallstone disease and to people with abdominal
or gastrointestinal symptoms that have not responded to
previous management. [Based on moderate to very low
quality observational studies]
Consider magnetic resonance cholangiopancreatography
if ultrasound has not detected common bile duct stones but
the:
-Bile duct is dilated or
-Liver function test results are abnormal (or both).
[Based on moderate to very low quality observational
studies]
Correspondence to: S Warttig sheryl.warttig@nice.org.uk
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Page 1 of 2
PRACTICE
Consider endoscopic ultrasound if magnetic resonance
cholangiopancreatography does not allow a diagnosis to
be made. [Based on moderate to very low quality
observational studies]
Treating asymptomatic gallbladder stones
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.
[Based on the experience and opinion of the Guideline
Development Group (GDG)]
Treating symptomatic gallbladder stones and
symptomatic or asymptomatic common bile
duct stones
Offer laparoscopic cholecystectomy to people diagnosed
with symptomatic gallbladder stones. [Based on moderate
to low quality randomised controlled trials and an original
health economic model]
Offer bile duct clearance and laparoscopic cholecystectomy
to people with symptomatic or asymptomatic common bile
duct stones. [Based on moderate quality randomised
controlled trials and an original health economic model]
Offer day case laparoscopic cholecystectomy to people
who are having this operation as an elective planned
procedure unless their circumstances or clinical condition
make an inpatient stay necessary. [Based on moderate to
low quality randomised controlled trials and an original
health economic model]
Offer early laparoscopic cholecystectomy (to be carried
out within one week of diagnosis) to people with acute
cholecystitis. [Based on moderate to low quality
randomised controlled trials and an original health
economic model]
Clear the bile duct:
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BMJ 2014;349:g6241 doi: 10.1136/bmj.g6241 (Published 30 October 2014)
-Surgically at the time of laparoscopic cholecystectomy or
-With endoscopic retrograde cholangiopancreatography
before or at the time of laparoscopic cholecystectomy.
[Based on very low quality randomised controlled trial
evidence and an original health economic model]
People with gallstone disease in whom
surgery or ductal clearance is inappropriate
Reconsider laparoscopic cholecystectomy for people who
have had percutaneous cholecystostomy once they are well
enough for surgery, regardless of age and comorbidities.
[Based on the experience and opinion of the GDG]
If the bile duct cannot be cleared with endoscopic
retrograde cholangiopancreatography, use biliary stenting
to achieve biliary drainage as a temporary measure only
until definitive endoscopic or surgical clearance. [Based
on the experience and opinion of the GDG]
Eating and drinking after cholecystectomy
Advise people that they should not need to avoid the food
and drink that triggered their symptoms after they have
their gallbladder or gallstones removed. [Based on the
experience and opinion of the GDG]
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, because they may
have another underlying condition that needs investigation.
[Based on the experience and opinion of the GDG]
Overcoming barriers
Hospital services and those commissioning hospital services
will need to review policies on the management of patients with
gallstone disease. This may involve rearranging surgical lists
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Page 2 of 2
PRACTICE
so that laparoscopic cholecystectomy can be offered to patients
with acute cholecystitis within one week of diagnosis, and
scheduling radiological and surgical lists to enable endoscopic
retrograde cholangiopancreatography to be delivered to patients
with common bile duct stones at the time of laparoscopic
cholecystectomy.
The members of the Guideline Development Group were: Gary McVeigh
(chair), Elaine Dobinson Evans, Simon Dwerryhouse, Rafik Filobbos,
Imran Jawaid, Angela Madden (co-opted expert), Peter Morgan, Gerri
Mortimore, Kofi Oppong, Charles Rendell, Richard Sturgess, Giles
Toogood, and Luke Williams. The technical team at NICE included
Gabriel Rogers, Steven Ward, and Sheryl Warttig.
Contributors: SW wrote the first and subsequent drafts of this summary.
All authors reviewed the drafts, were involved in writing further drafts,
and reviewed and approved the final version for publication. SW is
guarantor.
Competing interests: We have read and understood BMJ policy on
declaration of interests and declare the following interests: All authors
are employees of the National Institute for Health and Care Excellence,
which is commissioned and funded by the Department of Health to
develop clinical guidelines. The authors full statements can be viewed
at www.bmj.com/content/bmj/349/bmj.g6241/related#datasupp.
Provenance and peer review: Commissioned; not externally peer
reviewed.
1 Halldestam I, Enell EL, Kullman E, Borch K. Development of symptoms and complications
in individuals with asymptomatic gallstones. Br J Surg 2004;91:734-8.
2 NHS Choices. Cholecystitis, acute. 2014. www.nhs.uk/conditions/Cholecystitis-acute/
Pages/Introduction.aspx.
3 National Institute for Health and Care Excellence. Gallstone disease. Diagnosis and
management of cholelithiasis, cholecystitis and choledocholithiasis. (Clinical Guideline
4
188.) 2014. www.nice.org.uk/CG188.
National Institute for Health and Care Excellence. The guidelines manual. 2012. www.
nice.org.uk/article/PMG6/chapter/1%20Introduction.
5 National Institute for Health and Care Excellence. Gallstones. Information for the public
on NICE guideline CG188. 2014. www.nice.org.uk/guidance/cg188/informationforpublic.
Cite this as: BMJ 2014;349:g6241
BMJ Publishing Group Ltd 2014
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BMJ 2014;349:g6241 doi: 10.1136/bmj.g6241 (Published 30 October 2014) Page 3 of 2

PRACTICE

Further information on the guidance

Methods
The Guideline Development Group (GDG) followed standard National Institute for Health and Care Excellence (NICE) methods in the
development of this guideline.4 The GDG included a consultant upper gastrointestinal surgeon, a consultant hepatobiliary and liver transplant
surgeon, two consultant gastroenterologists, a hepatobiliary clinical nurse, two consultant gastrointestinal radiologists, an anaesthetist, a
general practitioner, and two patient or lay members. The group also co-opted a dietitian.
The GDG developed the review questions. To answer these questions, the NICE systematic reviewing team identified and analysed the
clinical and health economic evidence. Meta-analysis, network meta-analysis, narrative analysis, and health economic modelling were
undertaken whenever appropriate. GRADE methodology was also applied to develop quality ratings for the body of evidence. The GDG
appraised and interpreted the evidence to develop the recommendations and research recommendations. A draft guideline, which went
through a quality assurance process, was developed. The draft guideline was consulted on by a range of stakeholders who were invited to
comment, and all comments were considered by the GDG when producing the final version of the guideline.
Further updates of the guideline will be produced as part of NICEs guideline development programme.
NICE has produced four different versions of the guidance: a full version; a summary version known as the NICE guidance; a pathway;
and a version for people using NHS services, their families and carers, and the public.5 All these versions, together with a suite of tools to
help with implementation of the guidance, are available from the NICE website.3 Further updates of the guidance will be produced as part
of NICEs guideline development programme.

Future research
The GDG identified the following areas for future research:
What are the long term benefits and harms and cost effectiveness of endoscopic ultrasound (EUS) compared with magnetic resonance
cholangiopancreatography (MRCP) in adults with suspected common bile duct stones?
What are the benefits and harms, and cost effectiveness of routine intraoperative cholangiography in people with low to intermediate
risk of common bile duct stones?
What models of service delivery enable intraoperative endoscopic retrograde cholangiopancreatography (ERCP) for bile duct clearance
to be delivered within the NHS? What are the costs and benefits of different models of service delivery?
In adults with common bile duct stones, should laparoscopic cholecystectomy be performed early (within two weeks of bile duct clearance),
or should it be delayed (until six weeks after bile duct clearance)?
What is the long term effect of laparoscopic cholecystectomy on outcomes that are important to patients?

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