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Sanders and Kingsnorth gave a less than comprehensive view of their subject.1 Really important gallstones that must be dealt with occur in the bile ducts. Where is the discussion about diagnosis with magnetic resonance imaging and computed tomography, management with therapeutic endoscopic retrograde cholangiopancreatography, the place of open surgery, and discussion of optimal antibiotic therapy of ascending cholangitis in 2007?
Of course more cholecystectomies are done in the United States (population 290 million) than in England (population 49 million). The interesting thing is that the rate per head of population is much greater in the financially driven healthcare system in the US compared with our public service ethos. The prevalence of gallstones is probably the same.
Andy Warhol died at 58 after apparently routine surgery for gallstones. Surely death is the most serious complication of operative treatment. Gallbladder gallstones are no more likely to kill patients than the low mortality of their surgical treatment. This points out the apparent arbitrariness of the decision to operate in many cases.
Ursodeoxycholic acid is useful to prevent gallstones in the weight loss period after bariatric surgery and should be routinely considered. But it is also indicated for prophylaxis in octreotide and somatostatin therapy, which is probably the most potent iatrogenic cause of stones. Although it has a very small place in therapy, two thirds of lucent gallbladder stones less than 5 mm in diameter can be dissolved, and it cannot be dismissed entirely as a treatment.
Forty year old women are not a prime risk group. They have fewer gallstones than men older than 70, and age is a crucial factor in the UK. Although more than two pregnancies and the oestrogen in hormone replacement therapy can cause gallstones, the oral contraceptive pill is not lithogenic. There are important racial and international geographical variations in gallstone prevalence, and a strong association with haemolytic anaemia.
Competing interests: None declared.