From the Guidelines
For treating cholelithiasis (gallstones) without bile duct dilation, the primary treatment is laparoscopic cholecystectomy, which involves surgical removal of the gallbladder. This is the definitive treatment for symptomatic gallstones when the bile ducts are of normal size, as recommended by the American College of Physicians 1. Prior to surgery, patients should manage symptoms with pain control using NSAIDs like ibuprofen (400-600mg every 6 hours) or naproxen (500mg twice daily), or if needed, opioid analgesics such as hydrocodone/acetaminophen (5-10mg/325mg every 4-6 hours) 1.
Some key points to consider in the management of cholelithiasis include:
- Dietary modifications are important while awaiting surgery; patients should follow a low-fat diet, avoid trigger foods, eat smaller frequent meals, and stay well-hydrated 1.
- For patients who are poor surgical candidates, alternative treatments include oral dissolution therapy with ursodeoxycholic acid (8-10mg/kg/day in 2-3 divided doses for 6-24 months), extracorporeal shock wave lithotripsy in specialized centers, or percutaneous cholecystostomy for acute cholecystitis in high-risk patients 1.
- These non-surgical approaches are less effective than cholecystectomy and have higher recurrence rates.
- Gallstones without symptoms (incidental findings) generally don't require treatment, as many remain asymptomatic.
- The surgical approach is preferred because it prevents recurrence by removing the gallbladder, which is the site of stone formation, as supported by guidelines from the American College of Physicians 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 Patients with calcified gallstones prior to treatment, or patients who develop stone calcification or gallbladder non-visualization on treatment, and patients with stones > 20 mm in maximal diameter rarely dissolve their stones.
Treating Cholelithiasis without Duct Dilation:
- Ursodiol can be used to treat cholelithiasis without duct dilation.
- The chance of gallstone dissolution is increased up to 50% in patients with floating or floatable stones.
- Complete dissolution was observed in 81% of patients with stones up to 5 mm in diameter.
- Key Considerations:
- Stone size: patients with stones < 20 mm in maximal diameter are more likely to experience complete stone dissolution.
- Stone composition: patients with uncalcified gallstones are more likely to experience complete stone dissolution.
- Treatment duration: treatment for up to 2 years may be necessary to achieve complete stone dissolution.
- Patient monitoring: 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) is a treatment option for symptomatic cholelithiasis, which can be used in combination with ursodiol to dissolve gallstone fragments 3, 4, 5, 6.
- The efficacy of ESWL with ursodiol is higher than ursodiol alone in patients with single or multiple gallstones 5, 6.
- Studies have shown that ESWL with ursodiol can achieve stone-free gallbladders in 21-63% of patients at 6 months and 45-85% at 12 months 3, 5, 6.
- The treatment is more effective for solitary than multiple stones, radiolucent than slightly calcified stones, and smaller than larger stones 3, 6.
- Ursodiol treatment can also be effective in clearing stones in patients with gallstone recurrence and reducing the risk of subsequent biliary symptoms in patients with residual stones 7.
Factors Affecting Treatment Outcome
- Gallbladder contractility is an important factor in stone recurrence after ESWL treatment, with better contractility associated with lower recurrence rates 7.
- Fragment size after ESWL treatment is also a significant factor, with smaller fragments (<3mm) associated with lower risk of biliary symptoms 7.
- Ursodiol administration for 6 months or more after ESWL treatment can effectively reduce the risk of subsequent biliary symptoms in patients with residual stones 7.
Adverse Effects and Complications
- Common adverse effects of ESWL with ursodiol include biliary colic, diarrhea, and acute cholecystitis 3, 4, 5.
- Severe complications such as acute pancreatitis, macroscopic hematuria, and perirenal hematoma are rare but can occur 4.
- The risk of stone recurrence and biliary symptoms after ESWL treatment can be managed with ursodiol therapy and close follow-up 7.