What is the management of gallstones?

Management of Gallstones

For patients with gallstones, the management approach should be based primarily on whether the stones are symptomatic or asymptomatic, with laparoscopic cholecystectomy being the treatment of choice for symptomatic gallstones.

Asymptomatic Gallstones

• Expectant management (watchful waiting) is recommended for patients with asymptomatic gallstones due to their benign natural history and low risk of complications 1
• This recommendation applies to men and women of all ages as the risks of surgical or nonsurgical intervention outweigh the benefits in asymptomatic patients 1
• The rate of development of moderate-to-severe symptoms or gallstone complications in patients with asymptomatic stones is estimated to be only 2-6% per year 2

Exceptions for Asymptomatic Patients

• Prophylactic cholecystectomy may be advisable for patients at high risk for gallbladder cancer, including: 1
  • Patients with calcified gallbladders
  • Native Americans (particularly Pima Indians)
  • Patients with large stones (>3 cm)

Symptomatic Gallstones

• Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstones 1, 3, 4
• Over 95% of gallbladders are now removed laparoscopically 1
• Benefits of laparoscopic cholecystectomy include: 3, 4
  • Shorter hospital stay (typically 1 day)
  • Faster return to normal activities (approximately 8 days)
  • Lower postoperative analgesic requirements
  • High success rate (>97% completion rate)

Decision-Making Algorithm for Symptomatic Patients

1. Determine if biliary pain is the first episode and confirm it is related to gallstone disease 1
2. Assess patient's treatment goals and attitudes toward preventing future episodes 1
3. For patients primarily concerned about preventing future pain episodes, treatment should be instituted 1
4. For patients with first episode of pain primarily concerned about mortality risk, observation may be reasonable (approximately 30% may not have recurrent episodes) 1
5. For patients desiring intervention, laparoscopic cholecystectomy by a skilled surgeon is generally preferred 1, 3

Special Considerations for Common Bile Duct Stones (CBDS)

• Intraoperative cholangiography (IOC) or laparoscopic ultrasound (LUS) is suggested for patients with intermediate to high pre-test probability of CBDS 1
• Extraction options for CBDS include: 1
  • Laparoscopic bile duct exploration (LBDE)
  • Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy
  • For difficult stones, cholangioscopy-guided lithotripsy may be necessary

Non-Surgical Options

Oral Dissolution Therapy (Ursodiol)

• Ursodiol may be considered for select patients who are poor surgical candidates 1, 2
• Best candidates for oral bile acids have: 1, 2
  • Small stones (<0.5 cm diameter)
  • Stones that float during oral cholecystography
  • Radiolucent stones (cholesterol stones)
• Limitations of ursodiol therapy: 2
  • Requires months of therapy
  • Complete dissolution occurs in only about 30% of unselected patients
  • Stone recurrence within 5 years in up to 50% of patients after dissolution
  • Does not reduce risk of gallbladder cancer

Lithotripsy

• Best candidates for lithotripsy have: 1
  • Solitary radiolucent stone smaller than 2 cm
  • Should be used with adjuvant oral bile acids
• Lithotripsy is rarely used as primary therapy in current practice 5

Preventive Therapy

• Ursodiol can reduce the risk of gallstone formation in high-risk situations such as: 2, 5
  • Rapid weight loss from very low calorie diets
  • After bariatric surgery
  • Doses of 300-600 mg/day significantly reduce gallstone formation compared to placebo

Pitfalls and Caveats

• Potential bile duct injury during laparoscopic cholecystectomy should be considered, especially when performed by less experienced surgeons 1
• Cholecystectomy should be performed within 24 hours of admission for acute cholecystitis to decrease morbidity and hospital length of stay 5, 6
• Non-surgical methods do not reduce the risk of gallbladder cancer 1
• For patients with gallbladder polyps, cholecystectomy is recommended if the polyp is larger than 1 cm 6
• After endoscopic clearance of common bile duct stones, cholecystectomy is still recommended if gallbladder stones are present, as recurrent biliary events are significantly reduced 1