What is the management approach for someone presenting with gallbladder symptoms?

From the Guidelines

The management approach for someone presenting with gallbladder symptoms should prioritize laparoscopic cholecystectomy as the definitive treatment for symptomatic gallstones, as recommended by the most recent guidelines. This approach is supported by the 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis 1. For mild symptoms of biliary colic, conservative management includes pain control with NSAIDs like ibuprofen (400-600mg every 6 hours) or ketorolac (30mg IV or 10mg orally), and antiemetics such as ondansetron (4-8mg) for nausea. Patients should follow a low-fat diet to reduce gallbladder contractions and subsequent pain.

Key Considerations

• The estimated overall prevalence of gallstones is 10–15% in the general population, with some differences across countries 1.
• Between 20 and 40% of patients with gallstones will develop gallstone-related complications, with an incidence of 1–3% annually; acute calculus cholecystitis (ACC) is the first clinical presentation in 10–15% of the cases 1.
• Cholecystectomy is the most common therapeutic approach for ACC and is considered the standard of care for gallstone disease for the majority of patients 1.

Treatment Options

• For acute cholecystitis, hospitalization is often necessary with IV antibiotics such as piperacillin-tazobactam (3.375g every 6 hours) or a combination of ceftriaxone (1-2g daily) and metronidazole (500mg every 8 hours) for 5-7 days.
• For patients who are poor surgical candidates, alternatives include percutaneous cholecystostomy tube placement for drainage or dissolution therapy with ursodeoxycholic acid (8-10mg/kg/day) 1.
• The choice of treatment should be based on the patient's treatment goals and attitudes, as well as the natural history of the disease, which can be roughly estimated using natural history data 1.

Recent Guidelines

• The 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis recommend laparoscopic cholecystectomy as the definitive treatment for symptomatic gallstones 1.
• The guidelines also discuss the importance of considering the patient's risk factors, such as age and comorbidities, when deciding on the best course of treatment 1.

From the FDA Drug Label

Watchful waiting has the advantage that no therapy may ever be required. For patients with silent or minimally symptomatic stones, the rate of development of moderate-to-severe symptoms or gallstone complications is estimated to be between 2% and 6% per year, leading to a cumulative rate of 7% to 27% in 5 years Presumably the rate is higher for patients already having symptoms. Cholecystectomy For patients with symptomatic gallstones, surgery offers the advantage of immediate and permanent stone removal, but carries a high risk in some patients.

The management approach for someone presenting with gallbladder symptoms includes:

• Watchful waiting: may be considered for patients with silent or minimally symptomatic stones, as the rate of development of moderate-to-severe symptoms is relatively low.
• Cholecystectomy: may be considered for patients with symptomatic gallstones, as it offers immediate and permanent stone removal, but carries a high risk in some patients, particularly those with severe or extreme systemic disease 2. Key considerations include the patient's age, presence of disease other than cholelithiasis, and overall health status.

From the Research

Management Approach for Gallbladder Symptoms

The management approach for someone presenting with gallbladder symptoms typically involves a combination of diagnostic tests and treatment options.

• Initial management includes intravenous hydration and antibiotics, bowel rest, and analgesia, as seen in cases of acute cholecystitis 3.
• For complicated cases, surgery (laparoscopic cholecystectomy) is often the recommended course of action 3, 4.
• The goal of management in individuals with choledocholithiasis consists of clearing common bile duct stones, and may involve endoscopic sphincterotomy (ES) followed by cholecystectomy 5.
• In cases of acute ascending cholangitis, treatment includes intravenous fluids, analgesia, intravenous antibiotics, and biliary drainage and decompression 6.

Diagnostic Considerations

• Diagnostic tests such as abdominal computerized tomography (CT) scan, right upper quadrant (RUQ) abdominal ultrasound, and hepatobiliary iminodiacetic acid (HIDA) scan can be used to diagnose gallbladder disease 3.
• Laboratory results, including white blood cell count, aspartate aminotransferase (AST), alanine transaminase (ALT), and total bilirubin, can also be used to support diagnosis 3.
• Physical exam findings, such as epigastric tenderness and Murphy's sign, can be used to support diagnosis, although these findings may not always be present 3.

Treatment Options

• Cholecystectomy is a common treatment option for gallbladder disease, and can be performed laparoscopically 3, 4, 5.
• Endoscopic sphincterotomy (ES) may be used to clear common bile duct stones in cases of choledocholithiasis 5.
• Supportive care, including intravenous hydration and antibiotics, bowel rest, and analgesia, may be used to manage symptoms and support recovery 3, 6.