What are the treatment options for gallstones?

Medical Treatment of Gallstones

Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstones, while asymptomatic gallstones generally require no intervention and can be managed with watchful waiting. 1

Treatment Algorithm Based on Symptom Status

Asymptomatic Gallstones

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

  • Only 10-25% progress to symptomatic disease
  • Only 1-2% develop serious complications annually
  • Up to 80% remain asymptomatic throughout life

• Baseline assessment should include:

  • Documentation of stone size, number, and location
  • Baseline liver function tests
  • Patient education about potential symptoms 1

• Prophylactic cholecystectomy may be considered only in specific high-risk groups:

  • Patients with calcified gallbladders
  • Large stones (>3 cm)
  • Populations with high gallbladder cancer risk 1

Symptomatic Gallstones

1. Surgical Management:

   • Laparoscopic cholecystectomy: First-line treatment for symptomatic gallstones 1

     • Early cholecystectomy (within 7-10 days of symptom onset) is preferred for acute cholecystitis
     • Benefits include shorter hospital stay, fewer complications, and lower costs

   • Open cholecystectomy: Reserved for complex cases or when laparoscopic approach fails 1

   • Percutaneous cholecystostomy: Bridge to cholecystectomy for high-risk patients 1

2. Non-surgical Management (for patients unfit for surgery):

   • Oral bile acid dissolution therapy with ursodeoxycholic acid (10 mg/kg/day) or chenodeoxycholic acid (15 mg/kg/day) 1, 2

     • Only effective for:
       • Radiolucent (cholesterol-rich) stones
       • Patent cystic duct
       • Small stones (<6mm) respond best 2
     • Complete dissolution rates up to 75% annually with careful patient selection 2
     • Caution: Recurrence rates up to 50% within 5 years after dissolution 3

   • Lithotripsy combined with bile acids: For single stones <30mm or multiple stones (n<3) 2

     • Annual dissolution rates approximately 80% for single stones and 40% for multiple stones

Management of Complications

Acute Cholecystitis

• Early laparoscopic cholecystectomy (within 24 hours of admission) 4
• Antibiotic therapy:
  • One-shot prophylaxis if early intervention is planned
  • 4-day course for immunocompetent patients with complicated cholecystitis
  • Up to 7-day course for immunocompromised or critically ill patients 1

Common Bile Duct Stones

• Laparoscopic bile duct exploration (LBDE) or endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction 1
• For patients with gallstone pancreatitis and cholangitis or biliary obstruction:
  • Biliary sphincterotomy and endoscopic stone extraction within 72 hours 1
  • Urgent biliary decompression within 24 hours for severe sepsis or cholangitis 1

Biliary Colic

• Pain management with nonsteroidal anti-inflammatory drugs and spasmolytics
• Opioids for severe pain 4

Special Populations

Pregnancy

• Early laparoscopic cholecystectomy is recommended during all trimesters
• Lower risk of maternal-fetal complications with early intervention 1

Elderly and High-Risk Patients

• Frailty assessment is more important than chronological age in determining surgical risk 1
• Contraindications for cholecystectomy:
  • Inability to tolerate general anesthesia
  • Uncontrolled coagulopathy
  • End-stage liver disease with portal hypertension 1
• Biliary sphincterotomy and endoscopic duct clearance as an alternative for prohibitive surgical risk 1

Prevention Strategies

• Weight maintenance and avoiding rapid weight loss
• For patients undergoing significant weight reduction (diet or bariatric surgery), ursodeoxycholic acid can reduce the risk of gallstone formation 4
• Physical activity may help prevent gallstone formation 5

Important Caveats

1. Surgical risk varies significantly with age and comorbidities:

   • Mortality rates range from 0.054% in healthy women under 49 years to >10% in high-risk patients with severe systemic disease 3
   • Common duct exploration quadruples mortality rates in all categories 3

2. Non-specific symptoms like bloating, belching, or fatty food intolerance should not be mistaken for gallstone-related symptoms 1

3. Medical dissolution therapy limitations:

   • Requires months of treatment
   • Does not work for all patients
   • High recurrence rates (up to 50% within 5 years) 3
   • May cause gastrointestinal side effects 6

4. Post-cholecystectomy considerations:

   • About 5% of patients have residual symptoms or retained common duct stones 3
   • Most patients can be discharged within 1-2 days after laparoscopic cholecystectomy 1