What is the primary treatment for cholelithiasis (gallstones)?

Treatment of Cholelithiasis (Gallstones)

For symptomatic gallstones, laparoscopic cholecystectomy is the primary treatment of choice to prevent future biliary pain, complications, and mortality. 1

Management Algorithm Based on Symptom Status

Asymptomatic Gallstones

• Expectant management is recommended for most patients with asymptomatic gallstones 1

  • This applies to both men and women of all ages
  • The benign natural course (80% remain asymptomatic throughout life) makes observation the safest approach 1
  • Only 10-25% of asymptomatic cases progress to symptomatic disease 2

• Exceptions requiring consideration of prophylactic cholecystectomy:

  • Patients at high risk for gallbladder cancer:
    • Those with calcified gallbladders
    • New World Indians (e.g., Pima Indians)
    • Patients with large stones (>3 cm) 1
  • Incidentally during another abdominal operation 1

Symptomatic Gallstones

1. Confirm biliary origin of symptoms:

   • Classic biliary pain: Right upper quadrant pain, often with radiation to right shoulder/scapula
   • Positive Murphy's sign, nausea, vomiting 3
   • Note: Dyspeptic symptoms (indigestion, flatulence, bloating) are less likely to resolve after surgery 1

2. Surgical intervention:

   • Laparoscopic cholecystectomy is the treatment of choice 1, 4
     • Benefits include significantly less postoperative pain, shorter hospitalization, and faster recovery 4
     • Most patients resume normal activities within 1 week 4
   • Open cholecystectomy may be necessary in certain cases (severe acute cholecystitis, upper abdominal scarring) 4

3. Non-surgical options (for patients who refuse surgery or have high surgical risk):

   • Oral bile acids (ursodeoxycholic acid) for selected patients 1, 5
     • Best candidates: Small stones (<0.5 cm) that float during oral cholecystography 1
   • Extracorporeal shock-wave lithotripsy for solitary radiolucent stones <2 cm 1

Important Considerations and Pitfalls

• Surgeon experience matters: The most significant risk factor for bile duct injury during laparoscopic cholecystectomy is surgeon inexperience 6

  • Major biliary injuries often require complex repairs (Roux-en-Y hepaticojejunostomy) 6
  • Ensure the surgeon is appropriately qualified and experienced 1

• Symptom evaluation: Dyspeptic symptoms (indigestion, bloating, flatulence) are less likely to resolve with cholecystectomy than classic biliary pain 1

  • Additional testing like CCK-cholescintigraphy does not improve prediction of surgical outcomes beyond clinical judgment 1

• Timing: Gallstone disease treatment is usually not urgent unless complications (acute cholecystitis, cholangitis, pancreatitis) develop 1

  • However, referral to a surgeon and/or gastroenterologist within 2 weeks of initial symptomatic presentation is recommended regardless of severity 3

• Patient education: Patients should understand that non-surgical methods may not reduce the risk of gallbladder cancer 1

By following this evidence-based approach to cholelithiasis management, clinicians can optimize outcomes while minimizing unnecessary interventions, particularly for asymptomatic patients.