What is the primary treatment for cholelithiasis (gallstones)?

Treatment of Cholelithiasis (Gallstones)

For symptomatic gallstones, laparoscopic cholecystectomy is the primary treatment of choice due to its effectiveness in preventing future biliary pain, complications, and mortality. 1

Treatment Algorithm Based on Symptom Status

Asymptomatic Gallstones

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

  • This applies to both men and women of all ages
  • Rationale: Benign natural course with low risk of complications (only 10-25% progress to symptomatic disease) 2
  • 80% of patients with gallstones remain asymptomatic throughout their lives 1

• 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

Symptomatic Gallstones

1. Laparoscopic cholecystectomy is the treatment of choice 1, 3, 4

   • Advantages:
     • Definitive treatment
     • Lower morbidity and mortality compared to open surgery
     • Shorter hospital stay (87% discharged by first postoperative day) 5
     • Less postoperative pain and faster recovery (most resume normal activities within 1 week) 5

2. Open cholecystectomy when laparoscopic approach is contraindicated or not feasible 1

   • Consider for severe acute cholecystitis or extensive upper abdominal scarring 5

3. Non-surgical options for select patients who are poor surgical candidates or refuse surgery 1, 6:

   • Oral dissolution therapy (ursodeoxycholic acid) 7, 6
     • Best for patients with small stones (<0.5 cm) that float during oral cholecystography
   • Extracorporeal shock wave lithotripsy
     • Best for solitary radiolucent stones <2 cm, with adjuvant oral bile acids 1

Clinical Decision-Making Process

1. Determine if symptoms are truly biliary in nature:

   • Classic biliary pain: Right upper quadrant or epigastric pain that may radiate to the right shoulder
   • Positive Murphy's sign on examination
   • Associated symptoms: nausea, vomiting 4

2. Assess symptom frequency and severity:

   • First episode vs. recurrent episodes
   • About 30% of patients with a single pain episode may not experience additional episodes 1

3. Consider patient factors:

   • Surgical risk
   • Patient preferences regarding surgical vs. non-surgical management
   • For high-risk surgical patients, non-surgical options may be reasonable 1

Important Caveats and Pitfalls

1. Dyspeptic symptoms (indigestion, flatulence, heartburn, bloating) are less likely to resolve following cholecystectomy 1

   • Avoid attributing these symptoms to gallstones without clear evidence of biliary origin

2. Cholecystokinin-cholescintigraphy (CCK-CS) adds little value in predicting surgical outcomes for patients with atypical symptoms 1

   • Clinical judgment remains superior for determining which patients will benefit from surgery

3. Conversion to open surgery may be necessary in approximately 8.5% of laparoscopic cholecystectomy cases 5

   • Patients should be informed of this possibility

4. Bile duct injury is a potential complication of laparoscopic cholecystectomy 1

   • Ensure surgeon is appropriately qualified and experienced

5. Referral timing: Individuals with established diagnosis of cholelithiasis should be referred to a surgeon and/or gastroenterologist within 2 weeks of initial presentation regardless of symptom severity or frequency 4

By following this treatment algorithm based on symptom status and individual risk factors, clinicians can optimize outcomes for patients with gallstones while minimizing unnecessary interventions.