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Editorial: Dangers of silent gall stones.

Gall stones occur in epidemic proportions in Britain. They may be found, though extremely rarely, in children or even in infants, but they then steadily increase in incidence in succeeding decades. Twenty years ago Hornl carried out a classical postmortem study in Birmingham in which he showed a 5.8% incidence of gall stones in all men over the age of 20 and an incidence of 13.2% in women; over the age of 70 the incidence rose to about 20% and the sex difference more or less disappeared. Since then the incidence of gall stones seems to have risen further.2 Many of these stones are symptomless and are discovered only because some are radio-opaque and may be seen on a plain x-ray film of the abdomen done for some other purpose; or they may be felt at laparotomy or noted at necropsy. Today more and more calculi are being discovered in extensive "executive check-ups", which may include barium studies and cholecystography. The management of these silent gall stones depends on a knowledge of their natural history; what risks are there of the development of any of the well-known complications of gall stones, and does the association between stones and cancer of the gall bladder present a serious risk to these patients ? Comfort, Gray, and Wilson3 studied 112 patients in whom stones were found by chance in operations for other conditions. At review 10-20 years later 51 of these patients (46%) had developed symptoms of biliary disease, and similar findings have been reported by other observers. A most elaborate investigation into this problem was that of Wenckert and Robertson4 from Malmo in Sweden. They followed up 781 patients with symptomless gall stones found on oral cholecystography who had, furthermore, remained free from symptoms for at least one year afterwards. After a further ten years half (49%) had remained asymptomatic or had only had mild symptoms, while the rest had developed the full range of complications. Attacks of colicky pain had occurred in 254 patients (33%) leading to elective surgery in 173 cases. Of the remaining 144 patients 59 had developed jaundice or pancreatitis or both; 81 had had attacks of cholecystitis, and 7 had died; 3 patients had developed cancer of the gall bladder, and 1 patient had developed obstruction. The incidence of complications was distinctly higher in those patients who were 60 years or more at the time of the primary cholecystography. As a guide, then, if patients with silent gall stones live long enough they have at least an even chance of developing symptoms, and these are likely to be more severe in the elderly. Cancers of the gall bladder and the extrahepatic biliary tract are fortunately rare-they account for less than 1% of deaths from malignant disease in Britain. However, the prognosis of this type of tumour is poor, apart from the occasional case when a small growth is found incidentally on pathological examination of a specimen removed because of stones. There is little doubt that gall-bladder cancer is associated with the presence of stones; Ellis5 found that reports ofstones coexisting with gall bladder cancer varied from 57 to 95% ofcases-far greater than the (albeit high) incidence of gall stones in the normal population. Though gall stones are less common in Japan than in the West a recent study by Sato and Matsushiro6 drew similar conclusions. In their postmortem studies gall stones were found in 4.3% of patients. In 48 patients with cancer of the gall bladder on whom information was available 32 (67%) proved to have complicating gall stones. The development of symptoms in patients with silent gall stones was found to be more sudden in the older age groups, where acute cholecystitis was likely to occur; and prognosis in such cases was generally grave. In spite of the risks of complications there is still one other factor we must consider before advising cholecystectomy in symptomless patients: operative mortality and morbidity. In an enormous collective review from Ohio7 of more than 28 000 cholecystectomies the overall mortality was 1.8%; but the mortality of elective surgery for chronic disease was 1.5% compared with 3-5% for patients with acute cholecystitis. In expert hands8 the mortality rate for cholecystectomy is well below 1%. Surgeons have differed in their views on whether cholecystectomy should be performed for symptomless gall stones because of the risk of malignant change. Supporters of operation point out the grave prognosis of the established disease, while others comment on the comparative rarity of cancer of the gall bladder. Overall, since patients with silent gall stones face a 50% chance of developing symptoms, and since this is particularly so in elderly patients, there is every reason to advise elective cholecystectomy whenever gall stones are discovered unless the general condition of the patient contraindicates surgery. At elective operation mortality will be kept to a minimum, far lower than might be expected in patients in whom severe symptoms intervene. At the same time, the risk of malignant change in the diseased gall bladder, small though it may be, is obviated.