What is the treatment for a contracted gallbladder?

Contracted Gallbladder: Definition and Treatment

Laparoscopic cholecystectomy is the gold standard treatment for a contracted gallbladder, which is a gallbladder that has become shrunken and fibrotic due to chronic inflammation. 1

What is a Contracted Gallbladder?

A contracted gallbladder is a condition where the gallbladder becomes smaller, fibrotic, and less functional due to:

• Chronic inflammation, often from long-standing gallstone disease 2
• Repeated episodes of cholecystitis causing scarring and contraction 3
• Advanced adenomyomatosis, which can lead to gallbladder wall thickening and contraction 4

Diagnosis

• Ultrasound is the initial imaging modality of choice for diagnosing gallbladder conditions, including contracted gallbladder 2
• CT scan may be used but has lower diagnostic accuracy than MRI for gallbladder conditions 4
• Contrast-enhanced ultrasound (CEUS) can help differentiate contracted gallbladder from other gallbladder lesions 4
• MRI/MRCP provides better visualization of the biliary tree and can be particularly useful in pregnant patients 5

Treatment Options

Surgical Management (Preferred)

• Laparoscopic cholecystectomy is the treatment of choice for symptomatic contracted gallbladder 1

  • Success rate exceeds 97% 1
  • Offers reduced recovery time compared to open surgery 6
  • Should be performed by experienced surgeons to minimize risk of bile duct injury 1, 6

• Surgical considerations for contracted gallbladder:

  • May be technically challenging due to fibrosis and inflammation 3
  • The Critical View of Safety (CVS) technique is essential to identify gallbladder elements safely 1
  • When CVS cannot be achieved, alternative techniques such as "fundus-first" approach, subtotal cholecystectomy, or conversion to open surgery should be considered 1

• Open cholecystectomy may be necessary in cases where:

  • Laparoscopic approach is technically challenging due to severe inflammation or fibrosis 3
  • There is concern for malignancy 6
  • Patient has extensive adhesions from previous surgeries 6

Non-Surgical Options (For Poor Surgical Candidates Only)

• Ursodeoxycholic acid (Ursodiol) may be considered for select patients who:

  • Are poor surgical candidates 1
  • Have small, floating, or radiolucent stones 1
  • Note: Complete dissolution does not occur in all patients, and recurrence of stones within 5 years has been observed in up to 50% of patients 7

• Extracorporeal Shock-Wave Lithotripsy (ESWL) may be used for:

  • Solitary radiolucent stones smaller than 2 cm 1
  • In combination with oral bile acids 1
  • Success rate is approximately 80% for single stones and 40% for multiple stones 1

Potential Complications and Considerations

• Bile duct injuries occur in 0.4-1.5% of laparoscopic cholecystectomies 6
• Combined bile duct and vascular injuries can occur, especially after conversion from laparoscopic to open cholecystectomy 6
• Post-cholecystectomy syndrome may occur, with symptoms including:
  • Abdominal pain, bloating, diarrhea, and dyspepsia 6
  • These symptoms are not attributable to gallstone disease but possibly related to alterations in bile flow after gallbladder removal 6

Recovery Expectations

• Laparoscopic cholecystectomy generally requires a shorter convalescence period compared to open cholecystectomy 6
• Hospital stay is typically shorter with the laparoscopic approach 6
• Open cholecystectomy may require up to several months to return to full activity 6

Special Considerations

• For patients with common bile duct stones, options include laparoscopic bile duct exploration or postoperative ERCP 1
• In cases of acute gallstone pancreatitis, laparoscopic cholecystectomy during index admission is recommended for mild cases 1
• Laparoscopic cholecystectomy can be performed safely in elderly patients, during pregnancy, and in patients with Child A or B cirrhosis, though with special precautions 6