What is the management and treatment approach for a patient with gallstones?

Patient Education for Gallstones

Understanding Your Gallstones

If you have gallstones without symptoms, you should not undergo treatment and can be safely monitored, as the risk of developing complications is only 2-5% per year and most people with gallstones never develop problems. 1, 2

What Are Gallstones?

• Gallstones are solid deposits that form inside your gallbladder, affecting up to 20% of adults 2, 3
• Most gallstones (80%) are made of cholesterol; others are pigment stones made of bilirubin 2
• Only 20-30% of people with gallstones ever develop symptoms or complications 2, 4

If You Have No Symptoms (Asymptomatic Gallstones)

Expectant management (watchful waiting) is recommended for all patients with asymptomatic gallstones, regardless of age or gender, because the risks of treatment outweigh the benefits. 1

Why No Treatment Is Recommended

• Your annual risk of developing moderate-to-severe symptoms is only 2-5% per year 5
• Your risk of serious complications is less than 1% annually 6
• Surgery and other treatments carry their own risks that exceed the low risk of complications from silent stones 1

Exceptions Requiring Prophylactic Surgery

You should consider cholecystectomy if you have: 1

• A calcified ("porcelain") gallbladder
• Stones larger than 3 cm in diameter
• Native American heritage (particularly Pima Indians or other New World Indians), as these groups have higher gallbladder cancer risk

If You Have Symptoms (Symptomatic Gallstones)

Laparoscopic cholecystectomy performed within 7-10 days of symptom onset is the preferred treatment for symptomatic gallstones, offering immediate and permanent stone removal with a >97% success rate. 7, 8

Recognizing True Gallstone Symptoms

Typical biliary pain (biliary colic) includes: 6

• Severe, steady pain in the upper right abdomen or center of the upper abdomen
• Pain that starts suddenly, often waking you from sleep
• Pain lasting hours to up to a day
• Pain that may radiate to your upper back
• Associated nausea

Atypical symptoms that are LESS likely to improve after surgery: 7

• Indigestion, flatulence, heartburn
• Bloating, belching
• General abdominal discomfort
• Food intolerances

What Happens After Your First Pain Episode

• Approximately 30% of patients never experience another episode of pain even without treatment 1, 7
• However, if symptoms recur, you face a 6-10% annual risk of recurrent symptoms and 2% annual risk of serious complications 6
• You should discuss with your physician whether to proceed with surgery immediately or observe the pattern of pain before deciding 1

Treatment Options Explained

Laparoscopic Cholecystectomy (Keyhole Surgery)

This is the gold standard treatment that removes your gallbladder permanently. 7, 8

Benefits: 7, 8

• Immediate and permanent stone removal
• Success rate exceeding 97%
• Prevents future pain, complications, stone recurrence, and gallbladder cancer
• Shorter recovery time compared to open surgery

Risks vary by your characteristics: 5

• Women under 49 in good health: 0.054% mortality risk (extremely low)
• Men have approximately twice the surgical mortality of women
• Risk increases with age and presence of other medical conditions
• Bile duct injury occurs in 0.4-1.5% of cases 7, 8

Non-Surgical Options (Limited Applicability)

Oral bile acid therapy (ursodiol) may be considered ONLY if you meet ALL these criteria: 8, 5

• You cannot or refuse to have surgery
• Your stones are small (less than 0.5-2 cm in diameter)
• Your stones are radiolucent (cholesterol-rich, not calcified)
• Your cystic duct is patent (open)
• You have increased surgical risk due to other medical conditions

Important limitations of ursodiol: 5

• Requires months to years of daily medication
• Complete dissolution does not occur in all patients
• Stone recurrence occurs in 30-50% of patients within 5 years after successful dissolution
• Does NOT prevent gallbladder cancer (unlike surgery)
• Requires serial ultrasound monitoring

Extracorporeal shock-wave lithotripsy (ESWL) may be considered if: 8, 5

• You have a single stone smaller than 2 cm
• The stone is radiolucent
• You use adjuvant bile acid therapy
• Success rate is approximately 80% for single stones but only 40% for multiple stones

Serious Complications to Watch For

Seek immediate medical attention if you develop: 4, 3

• Fever with abdominal pain (suggests acute cholecystitis)
• Persistent vomiting
• Yellowing of skin or eyes (jaundice, suggests bile duct obstruction)
• Severe upper abdominal pain radiating to the back (may indicate pancreatitis)

Common complications include: 4

• Acute cholecystitis (gallbladder inflammation)
• Acute pancreatitis (pancreas inflammation)
• Ascending cholangitis (bile duct infection)
• Gallstone ileus (bowel obstruction from migrated stone)

Prevention Strategies

If you are undergoing rapid weight loss (bariatric surgery or very low-calorie diet), ursodiol 600 mg daily can reduce gallstone formation from 23% to 1-3%. 5

General lifestyle measures to reduce gallstone risk: 9

• Maintain healthy weight and avoid obesity
• Eat regular meals at consistent intervals
• Consume a high-fiber, high-calcium diet
• Engage in regular vigorous exercise
• Avoid rapid weight loss without medical supervision

Common Pitfalls to Avoid

• Do not delay surgery if you have symptomatic stones, as the risk of complications increases over time 3
• Do not expect non-surgical therapies to work for large stones (>2 cm), as they are rarely effective 10, 8
• Do not assume dyspeptic symptoms (bloating, heartburn, indigestion) will resolve after surgery, as these atypical symptoms often persist 7
• Do not attempt non-surgical therapy if you have a contracted gallbladder with wall thickening, as this suggests chronic inflammation requiring surgery 10

Special Situations

If You Are Pregnant

• Laparoscopic cholecystectomy is safe during any trimester but ideally performed in the second trimester 7
• Conservative management has a 60% recurrence rate of biliary symptoms 7
• Same-admission cholecystectomy for acute biliary pancreatitis reduces early readmission by 85% 7

If You Have Bile Duct Stones

• ERCP (endoscopic procedure) is required for bile duct stone removal 7, 8
• Cholecystectomy should still be performed afterward to prevent recurrent biliary events 8

If You Are Too Sick for Surgery

• Percutaneous cholecystostomy (drainage tube) may be used as a temporary measure for acute cholecystitis 7, 8
• However, immediate laparoscopic cholecystectomy is superior even in high-risk patients and has fewer major complications 7, 8