Gallstone Size and Risk for Pancreatitis

In reply

Cohen has highlighted the uncertainties of ascribing risk based on findings from cross-sectional studies. A more valid estimate of the risk for pancreatitis among patients with gallstones of varying size must come from prospective cohort studies.

Nevertheless, our findings have implications for the treatment of patients after a first episode of uncomplicated biliary pain. Ransohoff and Gracie's¹ 1993 decision analysis compared expectant management with prophylactic cholecystectomy in patients with symptoms of gallstones. Their model demonstrated that a 50-year-old woman gains 104 days to her life expectancy with early surgery. This gain is greater than that predicted for many widely accepted preventive interventions, such as cervical cancer screening every 3 years from ages 20 to 75 years (96 days added to the life expectancy), breast cancer screening with annual physical examination and mammography for 10 years beginning at age 50 years (45 days added to the life expectancy), or reduction in serum cholesterol levels from 6.2 to 5.8 mmol/L (240 to 224 mg/dL) in a 40-year-old man (30 days added to the life expectancy).² Furthermore, because death due to gallstone disease is uncommon, the major factor guiding patient treatment should be the prevention of morbidity. Approximately 6% to 10% of unselected patients with symptomatic gallstones have recurrent symptoms annually, and 2% develop biliary complications.³ Given the likely higher risk for morbidity due to pancreatitis in patients with small gallstones, a decision for expectant management in that subgroup seems particularly ill-advised.