Episode 12: Ceftriaxone and gallstones
Author: Dr. Suneet Sood
Editor: Dr. Suneet Sood
Narrators: Thong Yi Kun, Alan Koay
Doctor, you are looking smug today, if you don’t mind my saying so!
Yes! I achieved an easy diagnosis today, but my colleagues think I’m brilliant!
Lucky you! What happened?
Well, I was having a much-needed post-surgery coffee with a group of other surgeons today, and this neurologist walks in. So a urologist sitting next to me asks him, why are you looking so glum, and the neurologist says, I’ve got a gallstone! I had some vague epigastric pain, and the radiologist picked up a small stone in my gall bladder! So the urologist says, that’s bad luck, that means surgery!
And my colleague, a general surgeon, pipes up. “Yup,” she says, “abdominal pain plus gallstone equals surgery.”
Then one of the gynaecologists adds, “And you’ve just recently come back from a bout of typhoid fever. Now you’ll be out for some more time.”
Oh, he had had typhoid! That’s not very common, is it?
No, but this chap has family in India, and had picked it up during a trip there. Anyway, the doctors start commiserating with this neurologist, and somebody turns to me and says, why are you so silent?
And, why were you so silent?
Ah! So I put on a thoughtful look, and asked the neurologist, “You had typhoid, didn’t you? They must have given you ceftriaxone?” And the neurologist says “Yes.” So I said, “Well, ceftriaxone causes gallstones. But if you wait, the gallstone will disappear.”
That’s exactly what everybody said, “Really?”. And they Googled it, and sure enough, the literature confirms that ceftriaxone causes gallbladder sludge, which often, but not always, disappears with time. It may form stones, and, indeed, cause gallstone disease.
What did the neurologist say?
Well, he thought I was brilliant, and so did the others.
The truth is, about six months ago a relative from India had called for this same problem. I had, I must admit, advised surgery. Luckily, before he was operated, somebody there told him to wait it out, and sure enough, after some time ultrasound confirmed that the gallstone had disappeared.
Ah, hence the smugness!
Yes. It was pure luck that I knew about this complication of ceftriaxone.
Why does ceftriaxone cause gallstones?
Ceftriaxone is excreted unchanged in the urine and bile, in roughly equal proportions. The gall bladder concentrates the bile, and if the patient is receiving ceftriaxone, a sludge may form. This sludge contains ceftriaxone and calcium, and small amounts of cholesterol and other compounds.
But sludge is not the same as actual gallstones.
No, but there are reports that the sludge may progress to stones in the gall bladder. There may even be stones in the bile duct. But overall, ceftriaxone precipitates are less of a problem than cholesterol or pigment stones.
- Bickford CL, Spencer AP. Biliary sludge and hyperbilirubinemia associated with ceftriaxone in an adult: case report and review of the literature. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2005;25(10):1389-95.