From the Guidelines
The recommended treatment for symptomatic cholelithiasis is laparoscopic cholecystectomy, which involves surgical removal of the gallbladder. This procedure is considered the gold standard treatment as it eliminates the source of stone formation and prevents recurrence of symptoms 1. The surgery typically requires 4 small incisions and patients usually recover within 1-2 weeks, with most returning to normal activities within a few days.
Key Considerations
- For patients who are poor surgical candidates due to comorbidities or who refuse surgery, alternative options include oral dissolution therapy with ursodeoxycholic acid (8-10 mg/kg/day in divided doses for 6-12 months), which works best for small, cholesterol-rich stones.
- Extracorporeal shock wave lithotripsy may be considered in select cases.
- Pain management during acute episodes includes NSAIDs like ketorolac (30mg IV or 10mg oral) or opioids if needed, and antispasmodics such as hyoscine butylbromide (10-20mg).
- Patients should follow a low-fat diet to reduce symptoms while awaiting definitive treatment.
Rationale
Surgery is preferred over medical management because gallstones frequently recur when treated non-surgically, and complications like acute cholecystitis, pancreatitis, or biliary obstruction may develop if left untreated 1. Laparoscopic cholecystectomy is a safe and feasible option for elderly patients with acute cholecystitis, with a low complication rate and shortened hospital stay 1.
Additional Guidance
- Percutaneous cholecystostomy can be considered in the treatment of acute cholecystitis patients who are deemed unfit for surgery 1.
- Early laparoscopic cholecystectomy should be performed as soon as possible, but can be performed up to 10 days of onset of symptoms 1.
From the Research
Treatment Options for Symptomatic Cholelithiasis
- Laparoscopic cholecystectomy is considered the treatment of choice for symptomatic cholelithiasis, offering less postoperative pain, hospitalization, and recuperation time 2, 3.
- The procedure has a low complication rate, with 4% major, 0% life-threatening, and 7.2% minor complications reported in one study 2.
- Most patients (87%) can be discharged by the first postoperative day, and normal activities can be resumed within 1 week after discharge 2.
Management of Choledocholithiasis
- Choledocholithiasis, the presence of bile duct stones, is a common condition associated with cholelithiasis, and its management is multidisciplinary 4.
- Treatment options include endoscopic and surgical approaches, with a debate on whether to perform a one-session or two-session treatment 4, 5.
- A single-stage procedure, such as laparoscopic cholecystectomy with common bile duct exploration, is a safe and effective option that may decrease the length of stay 5.
Comparison of Treatment Strategies
- A systematic review of treatment options for symptomatic cholelithiasis found that surgery, including laparoscopic cholecystectomy, is a common treatment strategy 6.
- The review highlighted the need for further studies to guide comparisons between the timing of surgery and watchful waiting to create standardized guidelines 6.
- Another study compared single-stage and multi-stage procedures for choledocholithiasis and found that single-stage procedures had a shorter hospital stay and comparable efficacy and morbidity rates 5.