What is the recommended treatment for symptomatic gallstones?

Treatment for Symptomatic Gallstones

Laparoscopic cholecystectomy is the definitive treatment of choice for symptomatic gallstones. 1 This surgical approach provides the most effective long-term resolution of symptoms and prevents future gallstone-related complications.

Diagnostic Evaluation

Before proceeding with treatment, proper diagnosis should be confirmed:

• Initial investigations:

  • Abdominal ultrasound (investigation of choice for gallstone diagnosis) 1
  • Complete blood count and liver function tests 1
  • HIDA scan (80-90% sensitivity) if diagnosis is uncertain 1

• Additional testing for suspected common bile duct stones:

  • Liver biochemical tests 1
  • MRCP (non-invasive with high accuracy) 1

Treatment Algorithm

1. Uncomplicated Symptomatic Gallstones

• First-line treatment: Laparoscopic cholecystectomy 1, 2
  • Should be performed within 24 hours of admission for uncomplicated cholecystitis 2
  • Associated with decreased morbidity, shorter hospital stays, and lower costs 2

2. Complicated Gallstone Disease

• Acute cholecystitis:

  • Start broad-spectrum antibiotics immediately upon diagnosis 1
  • Perform cholecystectomy within 2 weeks of presentation, preferably during the same admission 1

• Common bile duct stones:

  • Options include:
    • ERCP with biliary sphincterotomy and stone extraction (within 72 hours for acute cholangitis) 1
    • Laparoscopic bile duct exploration (LBDE) 1, 3
  • Cholecystectomy should follow endoscopic sphincterotomy to prevent recurrent stones 3

• Gallstone pancreatitis:

  • Early laparoscopic cholecystectomy within 2 weeks of presentation 1

3. Special Populations

• Elderly patients:

  • Age >65 alone is not a contraindication to cholecystectomy 1
  • Frailty assessment is more important than chronological age 1
  • Cholecystectomy can be safely performed up to 10 days from symptom onset 1

• High surgical risk patients:

  • Medical treatment may be considered for patients unfit for surgery 4
  • Requirements for medical dissolution therapy:
    • Cholesterol-rich (radiolucent) stones
    • Patent cystic duct
    • Options based on stone size:
      • Stones <6mm: Oral bile acids
      • Single stones <30mm: Lithotripsy with oral bile acids
      • Larger stones: Direct contact dissolution with methyltertbutylether

Post-Treatment Care

• Most patients can be discharged 1-2 days after laparoscopic cholecystectomy 1
• Follow-up at 7-10 days for wound evaluation 1

Important Considerations

• Asymptomatic gallstones typically do not require treatment 2, 3

• Conversion to open surgery should be considered in cases of:

  • Severe local inflammation
  • Adhesions
  • Bleeding from Calot's triangle
  • Suspected bile duct injury
  • Unclear anatomy 1

• Recurrence after non-surgical treatment: Following dissolution therapy, gallstones recur in approximately 50% of patients 4

• Prophylactic cholecystectomy is generally not recommended for asymptomatic gallstones except in specific high-risk groups:

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

The evidence strongly favors laparoscopic cholecystectomy as the definitive treatment for symptomatic gallstones, with timing and approach tailored to the specific presentation and complications. Medical therapy should be reserved for those who are truly poor surgical candidates.