From the Guidelines
Treatment of cholelithiasis without bile duct dilation should prioritize laparoscopic cholecystectomy for symptomatic patients, as it is the gold standard treatment that prevents future complications and recurrence, as recommended by the American College of Physicians 1.
Key Considerations
- Asymptomatic gallstones discovered incidentally may not require treatment, as many patients remain symptom-free.
- Symptomatic patients should undergo laparoscopic cholecystectomy, which is typically performed as a same-day procedure with 3-4 small incisions.
- For patients who are poor surgical candidates, medical dissolution therapy with ursodeoxycholic acid (Ursodiol) at 8-10 mg/kg/day in divided doses for 6-12 months may be attempted, though this is only effective for small, cholesterol-based stones and has high recurrence rates.
- Pain management during acute episodes includes NSAIDs like ketorolac (30mg IV or 10mg oral) or ibuprofen (400-600mg every 6 hours), and antispasmodics such as hyoscine butylbromide (10-20mg orally or IV).
- Dietary modifications including reduced fat intake and regular meal patterns may help manage symptoms while awaiting definitive treatment.
Rationale
The American College of Physicians recommends laparoscopic cholecystectomy as the preferred treatment for symptomatic gallstones without bile duct dilation 1. This approach prevents future complications, such as acute cholecystitis, pancreatitis, or biliary obstruction, and reduces the risk of gallstone recurrence and gallbladder cancer. While medical dissolution therapy may be considered for poor surgical candidates, its limited efficacy and high recurrence rates make it a less preferred option.
Additional Considerations
- The potential problem of bile duct injury should be considered, especially for laparoscopic cholecystectomy, and the clinician should determine if the surgeon is appropriately qualified and experienced in this new technology 1.
- Nonsurgical methods, such as oral bile acids and extracorporeal shock-wave lithotripsy, may be considered for patients who are good candidates, but these options have limited efficacy and may not prevent gallstone recurrence or gallbladder cancer 1.
- The decision between immediate treatment or expectant management should be based on the patient's treatment goals and attitudes, as well as the potential risks and benefits of each approach 1.
From the FDA Drug Label
The overall effect of ursodiol is to increase the concentration level at which saturation of cholesterol occurs The various actions of ursodiol combine to change the bile of patients with gallstones from cholesterol-precipitating to cholesterol-solubilizing, thus resulting in bile conducive to cholesterol stone dissolution. Complete stone dissolution can be anticipated in about 30% of unselected patients with uncalcified gallstones < 20 mm in maximal diameter treated for up to 2 years Partial stone dissolution occurring within 6 months of beginning therapy with ursodiol appears to be associated with a > 70% chance of eventual complete stone dissolution with further treatment;
Treating Cholelithiasis without Duct Dilation: Ursodiol can be used to treat cholelithiasis without duct dilation. The drug works by changing the bile composition to make it more conducive to cholesterol stone dissolution.
- Key Points:
- Complete stone dissolution can be anticipated in about 30% of unselected patients with uncalcified gallstones < 20 mm in maximal diameter treated for up to 2 years.
- Partial stone dissolution within 6 months is associated with a high chance of complete dissolution.
- Stone recurrence is possible after complete dissolution.
- Serial ultrasonographic examinations should be obtained to monitor for recurrence of stones. 2
From the Research
Treatment Options for Cholelithiasis without Duct Dilation
- Extracorporeal shock-wave lithotripsy (ESWL) with ursodiol has been shown to be effective in treating symptomatic gallstones, with a higher success rate compared to ursodiol alone 3, 4, 5
- The combination of ESWL and ursodiol has been found to be more effective for solitary stones, radiolucent stones, and smaller stones 3, 4, 5
- Ursodiol alone can also be used to dissolve gallstones, but its effectiveness is lower compared to ESWL with ursodiol 3, 4, 5
- A systematic review of treatment options for symptomatic cholelithiasis found that there is a gap in knowledge regarding the best treatment strategies, and further trials are needed to guide comparisons between different treatment methods 6
Efficacy and Safety of ESWL with Ursodiol
- ESWL with ursodiol has been found to be safe and effective, with few adverse events reported 3, 7, 4
- The most common adverse events associated with ESWL with ursodiol are biliary pain, diarrhea, and acute cholecystitis 3, 7, 4
- The efficacy of ESWL with ursodiol has been found to be higher for patients with single stones, radiolucent stones, and smaller stones 3, 4, 5
Comparison of Treatment Options
- A comparison of ESWL with ursodiol and ursodiol alone found that the combination of ESWL and ursodiol was more effective in achieving a stone-free gallbladder 4, 5
- A systematic review of treatment options for symptomatic cholelithiasis found that surgery, observation, lithotripsy, ursodeoxycholic acid, and pain-management strategies have been studied, but further trials are needed to guide comparisons between different treatment methods 6