Asymptomatic cholelithiasis in diabetes mellitus - to operate or not to operate, that is the question : review

The management of gallstones in diabetic patients has traditionally been considered problematic. Autopsy findings and uncontrolled studies have documented a higher prevalence of cholelithiasis in diabetes, and early reports have showed dramatically increased perioperative morbidity and mortality for the treatment of diabetics with acute cholecystitis. As a result, some authorities have recommended prophylactic cholecystectomy for diabetic patients with asymptomatic cholelithiasis, which is in contrast to recommendations for non-diabetics. More recent investigations have shown a comparable natural history, and operative morbidity and mortality for biliary surgery in diabetics when compared to a nondiabetics. Decision tree analyses have shown that prophylactic cholecystectomy confers no benefit and should not be routinely performed for diabetics with asymptomatic cholelithiasis. Cholecystectomy is indicated as is the case in the general population when symptoms develop. Asymptomatic gallstones are increasingly diagnosed today due to widespread use of abdominal ultrasonography for the evaluation of patients with foregut symptoms. Asymptomatic cholelithiasis, as defined by the Rome Group for the Epidemiology and Prevention of Cholelithiasis (GREPCO), is when gallstones are detected in the absence of gallstone-related symptoms, such as history of biliary pain (pain in the epigastrium or right upper abdominal quadrant that may radiate to the patient's back or the right scapula), or gallstone-related complications such as acute cholecystitis, cholangitis, or pancreatitis. Other nonspecific symptoms such as epigastric discomfort, dyspepsia, flatulence, nausea, abdominal gurgling noises, or abdominal pain at other sites, cannot be considered as symptomatic cholelithiasis and can be attributed to other gastrointestinal diseases such as peptic ulcer disease, and irritable bowel syndrome.