Management of Symptomatic Gallstones
Laparoscopic cholecystectomy is the gold standard treatment for patients presenting with symptomatic gallstones, and should be performed early (within 24 hours of admission) for acute cholecystitis. 1, 2, 3
Diagnosis and Evaluation
Initial Assessment
- Trans-abdominal ultrasound scanning (USS) and liver function tests (LFTs) are recommended for patients with suspected gallstones 4
- Normal results do not preclude further investigation if clinical suspicion remains high
- True biliary colic presents as:
- Sudden onset of severe, steady pain unaffected by remedies or position changes
- Distinguished from non-gallstone symptoms like belching, bloating, and fatty food intolerance 1
Suspected Common Bile Duct Stones (CBDS)
- MRCP is recommended if common bile duct stones are suspected 1
- CBDS are present in 10-20% of individuals with symptomatic gallstones 4
- Patients diagnosed with CBDS should be offered stone extraction, with greatest benefit for symptomatic patients 4
Treatment Algorithm
1. Symptomatic Uncomplicated Gallstones
- First-line treatment: Laparoscopic cholecystectomy 1, 2, 5
- Acute pain management:
- NSAIDs and spasmolytics; opioids for severe pain 2
2. Acute Cholecystitis
- Early laparoscopic cholecystectomy (within 24 hours of admission) 1, 3
- One-shot antibiotic prophylaxis if early intervention is planned 1
- For complicated cholecystitis: Antibiotic therapy for 4 days in immunocompetent patients, up to 7 days in immunocompromised or critically ill patients 1
3. Gallstone Pancreatitis with Cholangitis or Biliary Obstruction
- Biliary sphincterotomy and endoscopic stone extraction within 72 hours of presentation 1
- For severe sepsis or cholangitis: Urgent biliary decompression within 24 hours 1
- After successful endoscopic clearance of the biliary pathway, laparoscopic cholecystectomy within 72 hours 3
4. Common Bile Duct Stones (CBDS)
- Options for management include:
- Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction
- Laparoscopic bile duct exploration (LBDE) - either transcystic or transductal approach 4
- Both approaches are equally valid with no difference in efficacy, mortality, or morbidity, though LBDE is associated with shorter hospital stay 4
Special Populations
High-Risk or Elderly Patients
- Frailty assessment is more important than chronological age in determining surgical risk 1
- For patients with significant comorbidities or acute severe pancreatitis, cholecystectomy should be deferred until safe to operate 1
- Alternatives for high-risk patients:
Pregnancy
- Early laparoscopic cholecystectomy is recommended during all trimesters when indicated 1
- Lower maternal-fetal complications with early intervention
Non-Surgical Candidates
- In patients unable to undergo cholecystectomy, elective biliary sphincterotomy may reduce recurrent pancreatitis risk 1
- Medical dissolution therapy with bile acids (ursodeoxycholic acid or chenodeoxycholic acid) may be considered for:
Important Caveats
- Asymptomatic gallstones generally do not require intervention, with up to 80% remaining asymptomatic throughout life 1
- Contraindications for cholecystectomy include:
- Inability to tolerate general anesthesia
- Uncontrolled coagulopathy
- End-stage liver disease with portal hypertension 1
- Patients undergoing biliary sphincterotomy should have full blood count and coagulation studies (INR/PT) prior to ERCP 4
- For patients at high risk of post-ERCP pancreatitis, insertion of a pancreatic stent is suggested in addition to rectal NSAIDs 4
- Recurrence rates after medical dissolution therapy are high (approximately 50%) 6, 7