From the Guidelines
For patients with asymptomatic gallstones, expectant management is recommended, as the risks of surgical and nonsurgical intervention outweigh their benefits, according to the American College of Physicians guidelines 1. When considering treatment for cholelithiasis, it's crucial to differentiate between asymptomatic and symptomatic cases.
- Asymptomatic gallstones are generally managed expectantly, given the low risk of major complications and the potential risks associated with interventions 1.
- For symptomatic gallstones, the approach is more complex, involving an assessment of the patient's treatment goals, attitudes, and the natural history of their condition, as outlined in the guidelines 1.
Symptomatic Gallstones Treatment
For patients with symptomatic gallstones, the treatment aims to alleviate symptoms and prevent future episodes.
- Medications such as ursodeoxycholic acid (Ursodiol) may be used to dissolve cholesterol stones, although this method has limited success rates and is typically reserved for patients who cannot undergo surgery or prefer not to 1.
- Pain management is crucial during gallstone attacks, with NSAIDs like ibuprofen or naproxen, and antispasmodics such as hyoscyamine often recommended for symptom relief.
- Ultimately, surgical removal of the gallbladder (cholecystectomy) is the definitive treatment for most patients with symptomatic gallstones, due to the high recurrence rate of stones after medical dissolution therapy 1.
Considerations
- The decision to treat asymptomatic gallstones is influenced by factors such as the risk of gallbladder cancer, with certain populations like New World Indians and patients with calcified gallbladders or large stones (> 3 cm) potentially benefiting from prophylactic cholecystectomy 1.
- Patient preferences and treatment goals play a significant role in determining the approach to symptomatic gallstones, with some patients opting for observation after a first episode of pain, given that about 30% may not experience further episodes 1.
From the FDA Drug Label
The recommended dose for ursodiol capsules treatment of radiolucent gallbladder stones is 8 to 10 mg/kg/day given in 2 or 3 divided doses. Ultrasound images of the gallbladder should be obtained at 6-month intervals for the first year of ursodiol capsules therapy to monitor gallstone response Watchful waiting has the advantage that no therapy may ever be required. Cholecystectomy For patients with symptomatic gallstones, surgery offers the advantage of immediate and permanent stone removal, but carries a high risk in some patients.
The medical treatment for cholelithiasis (gallstones) includes:
- Ursodiol therapy: 8 to 10 mg/kg/day given in 2 or 3 divided doses for radiolucent gallbladder stones, with regular ultrasound monitoring to assess response 2
- Watchful waiting: for patients with silent or minimally symptomatic stones, with a cumulative rate of 7% to 27% developing moderate-to-severe symptoms or gallstone complications in 5 years 3
- Cholecystectomy: surgical removal of the gallbladder, offering immediate and permanent stone removal, but carrying a high risk in some patients, with mortality rates varying by age and presence of other diseases 3
From the Research
Medical Treatment for Cholelithiasis (Gallstones)
The medical treatment for cholelithiasis (gallstones) includes:
- Oral bile acid therapy, such as ursodiol or chenodiol, to dissolve cholesterol gallstones 4
- Extracorporeal shock-wave lithotripsy to fragment gallstones, which can then be dissolved with oral bile acids 5, 4
- Percutaneous cholecystolithotomy, a minimally invasive surgical method, for high-risk patients or those who wish to avoid anesthesia 6
Treatment Effectiveness
The effectiveness of these treatments varies:
- Ursodiol has been shown to be effective in dissolving gallstones, with 21% of patients having gallbladders free of stones after six months 5
- Extracorporeal shock-wave lithotripsy with ursodiol has been shown to be more effective than lithotripsy alone for the treatment of symptomatic gallstones 5
- Percutaneous cholecystolithotomy has been shown to be effective in clearing gallstones in 81% of patients, with complete symptom relief in over 95% of these patients 6
Comparison of Treatments
Comparing different treatments:
- Cholecystectomy has been shown to be superior to extracorporeal shock-wave lithotripsy in improving biliary colic and fatty food upset 7
- Extracorporeal shock-wave lithotripsy may not be able to clear all stones and harbors the possibility of stone recurrence, making cholecystectomy the preferred treatment modality in healthy patients with uncomplicated symptomatic gallstones 7