What are the treatment options for gallstones?

Treatment Options for Gallstones

For symptomatic gallstones, laparoscopic cholecystectomy is the preferred treatment option due to its effectiveness in permanently removing stones and preventing complications including gallbladder cancer. 1, 2

Treatment Algorithm Based on Symptom Status

Asymptomatic Gallstones

• Expectant management (watchful waiting) is recommended for patients with asymptomatic gallstones due to the low risk of developing complications 3
• This recommendation applies to all age groups and both genders, as the risks of intervention outweigh potential benefits 3
• The annual rate of developing moderate-to-severe symptoms from asymptomatic gallstones is only 2-6%, with a cumulative rate of 7-27% over 5 years 4

Exceptions for Asymptomatic Stones:

• Patients with high risk for gallbladder cancer should consider prophylactic cholecystectomy, including: 3
  • Those with calcified gallbladders
  • New World Indians (e.g., Pima Indians)
  • Patients with large stones (>3 cm)

Symptomatic Gallstones

Initial Assessment:

• Determine if biliary pain is the first episode and confirm it indicates gallstone disease 3
• Assess patient's treatment goals - prevention of future pain episodes or reduction of mortality risk 3
• For first episodes of pain, inform patients that approximately 30% may not experience additional episodes even with prolonged follow-up 3

Treatment Options:

1. Surgical Management (Preferred):

   • Laparoscopic cholecystectomy is the first-line treatment for symptomatic gallstones 1, 2
   • Benefits include immediate and permanent stone removal 4
   • Mortality rates vary by age and comorbidities: 4
     • Low-risk women under 49: 0.054% mortality
     • Mortality increases with age and presence of systemic disease
     • Men have approximately twice the surgical mortality rate of women

2. For Common Bile Duct Stones:

   • A one-step procedure with simultaneous laparoscopic cholecystectomy and common bile duct stone removal (either laparoscopically or endoscopically) is recommended 2
   • Magnetic resonance imaging or endoscopic ultrasound is recommended for diagnosis prior to surgical treatment 2
   • Common duct exploration increases mortality risk approximately four-fold across all patient categories 4

3. For Acute Cholecystitis:

   • Acute laparoscopic cholecystectomy is strongly recommended 2
   • Gallbladder drainage may be considered as an interval procedure before delayed laparoscopic cholecystectomy in patients with temporary contraindications to surgery 2

4. Non-surgical Options (for select patients):

   • Oral bile acids (ursodeoxycholic acid or chenodeoxycholic acid) for: 5

     • Patients unfit for or afraid of surgery
     • Small stones (<6 mm)
     • Radiolucent (cholesterol-rich) stones
     • Patent cystic duct (confirmed by gallbladder opacification on oral cholecystography)

   • Complete dissolution with ursodeoxycholic acid requires months of therapy and doesn't occur in all patients 4

   • Stone recurrence within 5 years occurs in up to 50% of patients after successful dissolution 4, 5

   • Lithotripsy combined with oral bile acids for: 5

     • Single stones <30 mm or multiple stones (n<3)
     • Annual dissolution rates: ~80% for single stones, ~40% for multiple stones

   • Direct contact dissolution using methyl-tert-butyl-ether: 5

     • Can dissolve stones of any size and number
     • Nearly 100% dissolution reported, but debris frequently remains
     • Still considered investigational 3

Special Considerations

• Patients with high surgical risk may benefit from non-surgical approaches, though these don't reduce gallbladder cancer risk 3, 5
• Bile duct injury is a potential complication of laparoscopic cholecystectomy - ensure surgeon is appropriately qualified and experienced 3
• For uncomplicated symptomatic gallstone disease, observation may be considered as an alternative to laparoscopic cholecystectomy in select cases 2
• Biliary colic can be treated with NSAIDs, spasmolytics, and opioids for severe pain while awaiting definitive treatment 6

Common Pitfalls to Avoid

• Delaying cholecystectomy in symptomatic patients increases risk of recurrence and complications 6
• Failing to assess surgical risk based on age and comorbidities 4
• Not considering the high recurrence rate (50%) after non-surgical treatments 4, 5
• Overlooking the need for immediate anti-infective therapy in acute cholangitis 6
• Performing prophylactic cholecystectomy for asymptomatic stones in patients without risk factors for gallbladder cancer 1