Management of Gallbladder Stones (Cholelithiasis)
Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstones, while asymptomatic gallstones generally should be managed expectantly without surgical intervention. 1
Diagnostic Approach
- Initial evaluation: Transabdominal ultrasound scanning and liver function tests are recommended for patients with suspected gallstones 1
- Additional imaging: MRCP is recommended if common bile duct stones are suspected 1
- Clinical features of symptomatic gallstones:
Treatment Algorithm
1. Asymptomatic Gallstones
- Recommended approach: Expectant management (no intervention) 1
- Only 10-25% progress to symptomatic disease
- Serious complications develop in only 1-2% of patients annually
- Patient education: Document stone presence, size, and number; obtain baseline liver function tests; educate about potential symptoms 1
- Exceptions where prophylactic cholecystectomy may be considered:
- Large stones (>3 cm)
- Calcified gallbladder
- Patients from populations with high gallbladder cancer risk 1
2. Symptomatic Gallstones
- First-line treatment: Laparoscopic cholecystectomy 3, 1, 4
- For patients with common bile duct stones (CBDS):
3. High-Risk or Inoperable Patients
- For prohibitive surgical risk: Biliary sphincterotomy and endoscopic duct clearance 3, 1
- Temporary measure: Short-term biliary stenting followed by further endoscopy or surgery 3
- Alternative for specific patients: Medical dissolution therapy with bile acids may be considered for:
- Patients unfit for surgery
- Radiolucent (cholesterol-rich) stones only
- Patent cystic duct
- Small stones (<6mm) 1
Important Considerations
Timing of Surgery
- Early cholecystectomy (within 1-3 days of diagnosis) is preferred over delayed cholecystectomy for acute cholecystitis 1
- Benefits include shorter hospital stay, fewer postoperative complications, and lower hospital costs 1
Risk Assessment
- 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
Post-ERCP Management
- For patients with gallbladder stones who undergo ERCP for common bile duct stones, subsequent cholecystectomy is recommended 1, 5
- Meta-analysis showed higher mortality in "wait and see" groups compared to prophylactic cholecystectomy groups (14.1% vs 7.9%) 3
- Secondary endpoints of recurrent pain, jaundice, and cholangitis were also significantly more common without cholecystectomy 3
Postoperative Care
- Most patients can be discharged within 1-2 days after laparoscopic cholecystectomy 1
- Follow-up at 7-10 days for wound evaluation and monitoring for symptom resolution 1
Common Pitfalls to Avoid
- Misattribution of symptoms: Non-specific symptoms like bloating, belching, or fatty food intolerance should not be mistaken for gallstone-related symptoms 1
- Unnecessary intervention: Routine cholecystectomy for all asymptomatic gallstones is not recommended 1, 5, 6
- Delayed treatment: Delaying cholecystectomy in acute cholecystitis increases complications and hospital costs 1
- Inadequate biliary drainage: Ensure adequate biliary drainage in patients with CBDS that have not been extracted 3
By following this evidence-based approach, patients with gallbladder stones can receive appropriate treatment that minimizes morbidity and mortality while maximizing quality of life.