What is the recommended treatment for symptomatic gallstones?

Treatment of Symptomatic Gallstones

Laparoscopic cholecystectomy is the first-line treatment for symptomatic gallstones due to its effectiveness in preventing future biliary pain, complications, and reducing the risk of gallbladder cancer. 1, 2, 3

Diagnostic Criteria for Symptomatic Gallstones

• Symptomatic gallstones typically present as sudden, severe, steady pain unaffected by household remedies, position change, or gas passage 4
• Symptoms may include biliary colic, acute cholecystitis, acute pancreatitis, common duct obstruction, ascending cholangitis, or gallstone ileus 4
• Ultrasonography is the investigation of choice for suspected gallstones 1
• Belching, bloating, intolerance of fatty foods, and chronic pain are not typically attributable to gallstone disease and are less likely to resolve following cholecystectomy 4, 1

Treatment Algorithm

For Uncomplicated Symptomatic Gallstones:

• Laparoscopic cholecystectomy is recommended as the standard treatment 1, 3, 5
• Early laparoscopic cholecystectomy (within 7-10 days of symptom onset) is recommended for uncomplicated cholecystitis 1
• Benefits include immediate and permanent stone removal with lower complication rates compared to open cholecystectomy 2
• One-shot antibiotic prophylaxis is recommended for uncomplicated cholecystitis with no post-operative antibiotics needed 1

For Complicated Presentations:

• For severe gallstone pancreatitis, urgent therapeutic ERCP with sphincterotomy should be performed within 72 hours after onset of pain, especially with cholangitis, jaundice, or dilated common bile duct 2
• Antibiotic therapy for 4 days is recommended for complicated cholecystitis if source control is adequate 1
• For gallbladder perforation, early diagnosis and immediate surgical intervention are critical to decrease morbidity and mortality rates 2

Special Populations

• For pregnant patients with symptomatic cholelithiasis, laparoscopic cholecystectomy is safe during any trimester but ideally performed in the second trimester 1
• Conservative management in pregnancy has a 60% recurrence rate of biliary symptoms, highlighting the importance of surgical intervention 1
• For high-risk patients unfit for surgery, percutaneous cholecystostomy is a safe and effective alternative treatment for acute cholecystitis 2
• Mortality rates for cholecystectomy vary by age and comorbidities, with lowest rates (0.054%) for low-risk women under 49 years 6
• Men have approximately twice the surgical mortality rate of women, and rates increase with age and presence of systemic disease 6

Non-Surgical Options

• For patients unfit for or afraid of surgery, oral bile acids (ursodeoxycholic acid or chenodeoxycholic acid) may be considered for select patients with:
  • Small stones (<6 mm) 7
  • Radiolucent (cholesterol-rich) stones 7
  • Patent cystic duct 7
• Ursodeoxycholic acid can achieve up to 75% complete dissolution annually in carefully selected patients 7
• Stone recurrence after dissolution with ursodiol therapy was seen within 2 years in 30% of patients, and up to 50% within 5 years 6
• Percutaneous cholecystostomy may be an option for acute cholecystitis in patients with multiple comorbidities unfit for surgery who don't improve with antibiotic therapy 1

Common Pitfalls and Considerations

• Failure to recognize that ambiguous or atypical symptoms (indigestion, flatulence, heartburn, bloating, belching, nausea) are less likely to resolve following cholecystectomy 1
• Delaying cholecystectomy beyond two weeks after discharge increases risk of potentially fatal recurrent acute pancreatitis 2
• Bile duct injury is a potential complication of laparoscopic cholecystectomy, making surgeon experience crucial 1, 2
• Risk factors for conversion to open cholecystectomy include age >65 years, male gender, acute cholecystitis, thickened gallbladder wall, diabetes mellitus, and previous upper abdominal surgery 2
• Approximately 30% of patients with a single pain episode may not experience additional episodes even with prolonged follow-up 4

Contrast with Asymptomatic Gallstones

• Expectant management is recommended for patients with asymptomatic gallstones due to the low risk of developing complications 4, 1
• Exceptions include patients with high risk for gallbladder cancer (calcified gallbladders, New World Indians, large stones >3 cm) who should consider prophylactic cholecystectomy 4, 1