Treatment of Symptomatic Cholelithiasis

Laparoscopic cholecystectomy is the first-line treatment and gold standard for symptomatic cholelithiasis. 1

Surgical Management

Early laparoscopic cholecystectomy (within 7-10 days of symptom onset) is recommended for uncomplicated cholecystitis 1
The procedure offers immediate and permanent stone removal with significantly less postoperative pain, shorter hospitalization, and faster recovery compared to open cholecystectomy 2
Most patients can be discharged by the first postoperative day and resume normal activities within 1 week 2, 3
Surgical mortality rates vary by age, gender, and comorbidities:
- Low-risk women under 49 years have the lowest mortality rate (0.054%)
- Men have approximately twice the surgical mortality rate of women
- Mortality increases significantly with age and presence of systemic disease 4

Pregnancy: Laparoscopic cholecystectomy is safe during any trimester but ideally performed in the second trimester 1
- Conservative management during pregnancy has a 60% recurrence rate of biliary symptoms 1
- Same-admission cholecystectomy in pregnant patients with acute biliary pancreatitis reduces early readmission by 85% 1
High-risk patients: For patients who are poor surgical candidates due to multiple comorbidities:
- Percutaneous cholecystostomy may be considered for acute cholecystitis in patients unfit for surgery who don't improve with antibiotic therapy 1
- However, cholecystostomy is inferior to cholecystectomy in terms of major complications for critically ill patients 1

For patients who are unfit for or refuse surgery, alternative treatments include:

Oral bile acids (ursodeoxycholic acid or chenodeoxycholic acid):
- Most effective for small stones (<6 mm)
- Requires radiolucent (cholesterol-rich) stones
- Patent cystic duct is necessary (confirmed by gallbladder opacification on oral cholecystography)
- Dosing: ursodeoxycholic acid 10 mg/kg/day or chenodeoxycholic acid 15 mg/kg/day 1, 5
- Bedtime administration of the whole daily bile acid dose enhances treatment efficacy 5
Extracorporeal shock-wave lithotripsy:
- Most effective for solitary radiolucent stones smaller than 2 cm
- Used with adjuvant oral bile acids 1
Direct contact dissolution using methyl-tert-butyl-ether:
- Can dissolve stones of any size and number
- Still considered investigational 1

Ultrasound is the investigation of choice for suspected acute cholecystitis 1
CT with IV contrast may be used as an alternative for diagnostic evaluation 1
MRCP (magnetic resonance cholangiopancreatography) is recommended for patients with suspected common bile duct stones 1

For patients with suspected common bile duct stones (10-20% of gallstone patients), additional management is required 6
Options include:
- Preoperative ERCP with endoscopic sphincterotomy followed by laparoscopic cholecystectomy 6
- Laparoscopic common bile duct exploration during cholecystectomy 6
- Laparoscopic cholecystectomy followed by postoperative ERCP if needed 6

One-shot prophylaxis is recommended for uncomplicated cholecystitis if early intervention, with no post-operative antibiotics 1
Antibiotic therapy for 4 days is recommended for complicated cholecystitis in immunocompetent non-critically ill patients if source control is adequate 1
Antibiotic therapy up to 7 days may be necessary for immunocompromised or critically ill patients based on clinical conditions and inflammation indices 1

Ambiguous or atypical symptoms (indigestion, flatulence, heartburn, bloating, belching, nausea) are less likely to resolve following cholecystectomy 1
Bile duct injury is a serious potential complication of laparoscopic cholecystectomy (reported in 0.2-0.5% of cases) 3, 7
Following non-surgical dissolution therapy, gallstones recur in about 50% of patients and cannot be reliably prevented by low-dose bile acid or dietary manipulations 5
CCK-cholescintigraphy does not add to clinical judgment alone in predicting surgical outcomes for patients with atypical symptoms 1