Most gallstones are composed largely or entirely of cholesterol. The larger calculi are more often associated with acute cholecystitis than are smaller stones. Factors predisposing to gallstone formation include sex, age, race, child-bearing, and possibly diet and obesity. About half of all persons with cholelithiasis have symptoms referable to the biliary tract. The most important symptom in the diagnosis of gallstone disease is biliary colic. Biliary pain lasting longer than five or six hours is indicative of acute cholecystitis, with obstruction of the cystic duct by a calculus as the primary event in most instances. The reliability of cholecystography in detecting gallstones is at least 95 percent. In patients over age 60, cholecystectomy is indicated only in those with specific symptoms referable to the biliary tract. The effectiveness of chenodeoxycholic acid in dissolving radiolucent gallstones in asymptomatic patients has been confirmed in several clinical trials. Early operation in patients with acute cholecystitis is advocated.
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