Gallstone Disease (Cholelithiasis) J001

Current RMA Instruments

Changes from previous Instruments

ICD Coding:

• ICD-10-AM Codes: K80, K80.01, K80.10, K80.11, K80.20, K80.21, K80.40, K80.41, K80.50

Brief description

The gallbladder is a small, pear-shaped organ located beneath the liver on the right side of the abdomen. Its main role is to store and release bile, a digestive fluid that helps break down fats in the small intestine. Gallstones are solid deposits formed from the bile components within the gallbladder. They may remain in the gallbladder, where they can cause inflammation (cholecystitis) or migrate into the biliary tract, where they can lead to obstruction and pain (biliary colic).

Confirming the diagnosis

The diagnosis may be suspected on clinical grounds but needs to be confirmed by imaging (abdominal ultrasound, CT scan, MRI) or via endoscopic retrograde cholangiopancreatography (ERCP).

General practitioners may suspect the diagnosis clinically and order initial investigations. However, if the condition becomes symptomatic, referral is often to an emergency physician, gastroenterologist or a hepatobiliary/general surgeon.

Additional diagnoses covered by SOP

• choledocholithiasis
• gallstones
• gallstones in bile ducts
• gallstones with cholecystitis

Conditions excluded from SOP

• Biliary colic from other causes #
• Cholecystitis in the absence of gallstones #

# non-SOP condition

Clinical onset

Gallstone disease may be asymptomatic and detected incidentally, or it may present with symptoms such as biliary colic or cholecystitis. For asymptomatic stones, clinical onset is taken as the time of diagnosis (usually by imaging). When symptoms are present, onset may be backdated to the first occurrence of characteristic features once the diagnosis has been confirmed.

Clinical worsening

Most individuals with asymptomatic gallstones will remain symptom-free. Among those who develop symptoms, a considerable proportion may progress to complications such as acute cholecystitis, choledocholithiasis (stone in the common bile duct) with or without acute cholangitis (infection and inflammation of the bile ducts), and gallstone pancreatitis.  Determining whether the course represents worsening beyond the expected natural history can be challenging and often requires specialist medical assessment. Management depends on the clinical presentation and may range from observation to surgical intervention.