Management of Gallstones
Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstones, while asymptomatic gallstones should be managed expectantly. 1
Asymptomatic Gallstones
- Expectant management 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 intervention outweigh the benefits in asymptomatic patients 1
- Exception: Consider prophylactic cholecystectomy for high-risk patients including those with calcified gallbladders, New World Indians, and patients with large stones (>3 cm) 2
Symptomatic Gallstones
- Early laparoscopic cholecystectomy (within 7-10 days of symptom onset) is the definitive treatment for uncomplicated cholecystitis 2, 3
- The Critical View of Safety technique should be used to identify gallbladder elements before clipping and dividing the cystic duct and artery 1
- Benefits include high success rate (>97% completion rate) and immediate, permanent stone removal 1, 4
- Mortality risk varies by age and comorbidities:
- Low-risk women under 49: 0.054% mortality
- Men have approximately twice the surgical mortality rate of women
- Rates increase with age and presence of systemic disease 4
Antibiotic Management
- One-shot prophylaxis is recommended for uncomplicated cholecystitis if early intervention, with no post-operative antibiotics 2, 3
- For complicated cholecystitis:
Special Clinical Scenarios
Common Bile Duct Stones
- Intraoperative cholangiography or laparoscopic ultrasound is suggested for patients with intermediate to high pre-test probability of common bile duct stones 1
- MRCP is recommended for patients with suspected common bile duct stones 2
- Extraction options include laparoscopic bile duct exploration or ERCP with sphincterotomy 1
- After endoscopic clearance of common bile duct stones, cholecystectomy is still recommended if gallbladder stones are present 1
Gallstone Pancreatitis
- For mild gallstone pancreatitis, perform cholecystectomy within 2-4 weeks 2
- For severe gallstone pancreatitis that fails to improve within 48 hours despite intensive resuscitation, perform urgent ERCP 2
- Same-admission cholecystectomy in pregnant patients with acute biliary pancreatitis reduces early readmission by 85% 2
Pregnancy
- Laparoscopic cholecystectomy is safe during any trimester but ideally performed in the second trimester 2
- Conservative management in pregnancy has a 60% recurrence rate of biliary symptoms 2
Non-Surgical Options for Poor Surgical Candidates
Percutaneous Cholecystostomy
- May be an option for acute cholecystitis in patients with multiple comorbidities unfit for surgery who don't improve with antibiotic therapy 2
- However, cholecystostomy is inferior to cholecystectomy in terms of major complications for critically ill patients 2
Oral Bile Acids
- Ursodiol (8-10 mg/kg/day in 2-3 divided doses) may be considered for select patients who are poor surgical candidates 1, 4
- Best candidates have:
- Ultrasound monitoring every 6 months is required to assess response 4
- Partial dissolution within 6 months indicates >70% chance of eventual complete dissolution 4
- Stone recurrence occurs in up to 50% of patients within 5 years of complete dissolution 4
Gallstone Prevention
- For patients undergoing rapid weight loss, ursodiol 600 mg/day (300 mg twice daily) is recommended for gallstone prevention 4
Common Pitfalls
- Ambiguous or atypical symptoms (indigestion, flatulence, heartburn, bloating, belching, nausea) are less likely to resolve following cholecystectomy 2
- Approximately 30% of patients may not experience additional episodes of biliary pain even with prolonged follow-up 2
- Bile duct injury is a potential complication of laparoscopic cholecystectomy (0.1-0.5% of cases), making surgeon experience an important consideration 1, 5
- Delaying cholecystectomy in mild gallstone pancreatitis beyond 4 weeks increases risk of recurrent attacks 2