From the Guidelines
Laparoscopic cholecystectomy is the recommended treatment for symptomatic cholelithiasis causing biliary colic, as it prevents future pain, complications, and gallstone recurrence, despite the associated risks of general anesthesia and postoperative morbidity. For asymptomatic gallstones, observation is generally recommended, as only 1-2% of patients develop symptoms per year 1. Biliary sludge, which consists of precipitated bile components that may precede stone formation, can be managed with observation if asymptomatic, while symptomatic cases warrant cholecystectomy.
Management Approaches
- Symptomatic cholelithiasis: laparoscopic cholecystectomy is the definitive treatment
- Asymptomatic gallstones: observation is recommended
- Biliary sludge: observation if asymptomatic, cholecystectomy if symptomatic
- Medical dissolution therapy with ursodeoxycholic acid (ursodiol) may be considered for small, cholesterol-rich stones in patients who refuse or cannot undergo surgery, though recurrence rates are high after discontinuation 1.
Risk Factors and Complications
- Risk factors for cholelithiasis and biliary sludge include female gender, obesity, rapid weight loss, pregnancy, and certain medications
- Complications of untreated symptomatic disease include acute cholecystitis, pancreatitis, and biliary obstruction, which require urgent intervention 1.
- Regular follow-up with ultrasound is recommended for asymptomatic cases to monitor for disease progression.
Recent Guidelines and Recommendations
- The American College of Radiology recommends biliary decompression in nearly all cases of acute biliary obstruction caused by choledocholithiasis, with initial medical management indicated to stabilize hemodynamic status and treat local and systemic infection 1.
- Endoscopic retrograde cholangiography (ERCP) has become the mainstay of treatment for choledocholithiasis, with a significant increase in utilization from 1998 to 2013 1.
From the Research
Definition and Prevalence of Cholelithiasis and Sludge
- Cholelithiasis, also known as gallstones, affects approximately 15% of the US population 2.
- Biliary sludge is a mixture of calcium bilirubinate and cholesterol monohydrate crystals that can be seen on transabdominal sonography 3.
- Cholelithiasis can result in complications, including cholecystitis and cholangitis 2.
Risk Factors and Symptoms
- Risk factors for cholelithiasis include modifiable and non-modifiable factors, with women being more likely to experience cholelithiasis than men 2.
- Pregnancy, increasing parity, and obesity during pregnancy further increase the risk of developing cholelithiasis 2.
- Symptoms of cholelithiasis include right upper quadrant pain, nausea, and vomiting, while biliary sludge can cause biliary-type pain, cholecystitis, cholangitis, or pancreatitis 2, 3.
Diagnosis and Management
- Ultrasonography is the gold standard for diagnosing cholelithiasis 2.
- Management of cholelithiasis depends on the severity and frequency of symptoms, with lifestyle and dietary modifications, medication management, and laparoscopic cholecystectomy being recommended options 2.
- Ursodeoxycholic acid (UDCA) is a bile acid that can dissolve gallstones and is used in the management of symptomatic gallstone disease 4, 5.
- Biliary sludge can be managed expectantly in asymptomatic patients, while cholecystectomy is recommended for patients who develop biliary-type pain, cholecystitis, cholangitis, or pancreatitis 3.
Treatment Options
- UDCA has been shown to be effective in dissolving gallstones, particularly in patients with persistent biliary sludge and microlithiasis 5.
- However, the evidence for UDCA in symptomatic gallstones is scarce and heterogenous, and clinicians require level 1 evidence to support its use 4.
- Cholecystectomy is a common treatment option for symptomatic cholelithiasis, with laparoscopic cholecystectomy being a recommended approach 6, 2.