What is the recommended management for a patient with gallstones?

From the Guidelines

The recommended management for a patient with gallstones is expectant management for asymptomatic patients and surgical intervention for symptomatic patients. The management of gallstones depends on whether the patient is symptomatic or asymptomatic. For asymptomatic gallstones, expectant management is recommended as the risk of complications is low and the effort and minor risks of surgical and nonsurgical intervention outweigh their corresponding benefits 1.

Asymptomatic Gallstones

• Expectant management is recommended for patients with asymptomatic gallstones, as they have a benign history and a low risk for ever incurring a major complication 1.
• Patients with a high risk for gallbladder cancer, such as those with calcified gallbladders or large stones, may be exceptions to this recommendation and may require prophylactic cholecystectomy 1.

Symptomatic Gallstones

• For symptomatic gallstones, the choice of treatment is more complicated and depends on the patient's treatment goals and attitudes 1.
• The clinician should determine if the biliary pain is the first episode and whether the pain indicates gallstone disease, and assess the patient's treatment goals and attitudes 1.
• If the patient primarily wants to reduce the risk for death from gallstones and if the pain is a first episode, then the patient may choose to observe the pattern of pain before deciding about therapy 1.
• Laparoscopic cholecystectomy is the definitive treatment for symptomatic gallstones causing biliary colic or complications, as it addresses the underlying problem by removing the gallbladder, preventing recurrence of stones and associated complications like acute cholecystitis, pancreatitis, or cholangitis.
• Prior to surgery, pain management with NSAIDs or opioids may be needed, and patients should follow a low-fat diet to reduce symptoms while awaiting surgery.
• In cases where surgery is contraindicated, ursodeoxycholic acid may be used to dissolve cholesterol stones, though this is less effective and recurrence is common.
• Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy may be necessary for patients with common bile duct stones, and antibiotics may be indicated for acute cholecystitis or cholangitis.

From the Research

Gallstones Management

The management of gallstones can be divided into several categories, including:

• Primary prevention: This involves preventing the formation of gallstones in the first place. According to 2, general "wellness" measures can be recommended, such as elimination of obesity, a high-fiber, high-calcium diet, and vigorous exercise.
• Secondary prevention: This involves preventing the clinical manifestations of gallstones, such as symptoms or complications. As stated in 2, secondary prevention is recommended only when gallstones become symptomatic.
• Nonsurgical management: This includes approaches such as dissolution with ursodiol, extracorporeal shock-wave lithotripsy, and contact dissolution with organic solvents. As mentioned in 2, nonsurgical therapy will be used by patients who cannot or will not have surgery.
• Surgical management: This involves the removal of the gallbladder, usually through laparoscopic cholecystectomy. According to 3, laparoscopic cholecystectomy is considered the most cost-effective management strategy in the treatment of symptomatic gallstones.

Asymptomatic Gallstones

For patients with asymptomatic gallstones, the management approach is more conservative. As stated in 4, asymptomatic gallstone disease has a benign natural course, and the progression of asymptomatic to symptomatic disease is relatively low. Therefore, most authors agree that the vast majority of subjects should be managed by observation alone (expectant management) 4.

• Expectant management: This involves monitoring the patient's condition and only intervening if symptoms develop. As mentioned in 5, asymptomatic patients have a low annual rate of developing symptoms (about 2% per year).
• Selective cholecystectomy: This involves removing the gallbladder in certain subgroups of patients who are at increased risk for developing gallstone-related symptoms and complications. According to 4, concomitant cholecystectomy is a reasonable option for good-risk patients with asymptomatic cholelithiasis undergoing abdominal surgery for unrelated conditions.

Symptomatic Gallstones

For patients with symptomatic gallstones, the management approach is more aggressive. As stated in 3, biliary pain is alleviated by cholecystectomy in the majority of cases.

• Laparoscopic cholecystectomy: This is considered the most cost-effective management strategy in the treatment of symptomatic gallstones 3.
• Medical management: This includes pain control with nonsteroidal anti-inflammatory drugs or narcotic pain relievers. According to 5, the management of acute biliary colic mainly involves pain control.
• Percutaneous cholecystostomy: This is an alternative for patients who are critically ill with gallbladder empyema and sepsis 5.