Management of Small Contracted Gallbladder with Cholelithiasis
Laparoscopic cholecystectomy is the definitive treatment of choice for a small contracted gallbladder with symptomatic cholelithiasis, and should be performed early—ideally within 7-10 days of symptom onset. 1, 2
Symptomatic vs. Asymptomatic Disease
If the Patient is Symptomatic (Biliary Pain):
- Proceed directly to laparoscopic cholecystectomy 1, 2
- Early surgery (within 7-10 days) results in shorter recovery time, reduced hospital stay, and lower conversion rates to open surgery compared to delayed approaches 1
- Over 95% of gallbladders are now removed laparoscopically 1
- A contracted gallbladder typically indicates chronic inflammation from recurrent episodes, making it a symptomatic condition requiring intervention 2
If Truly Asymptomatic (Incidental Finding):
- Expectant management is appropriate for most patients 1, 3
- Approximately 80% of patients with asymptomatic gallstones remain asymptomatic throughout their lives 1
- Only 10-25% progress from asymptomatic to symptomatic disease 3
- Surgery is reserved for high-risk subgroups: those at risk for gallbladder cancer, patients with stones >2.5 cm, or when performing concurrent abdominal surgery 1, 4, 3
Critical Caveat: "Contracted" Gallbladder Context
A small contracted gallbladder is rarely truly asymptomatic—this finding typically represents chronic cholecystitis from repeated inflammatory episodes, making the patient symptomatic by definition 2. Therefore, the expectant management pathway rarely applies to this specific scenario.
Preoperative Evaluation for Common Bile Duct (CBD) Stones
Before proceeding to cholecystectomy, assess for choledocholithiasis:
Check liver function tests and look for CBD dilation on ultrasound 1
If CBD stones are suspected (elevated bilirubin, dilated CBD >6mm, or visible stones):
If no evidence of CBD stones, proceed directly to laparoscopic cholecystectomy with intraoperative cholangiography if doubt exists 1
Surgical Approach
Standard Technique:
- Laparoscopic cholecystectomy is superior to open surgery with faster recovery, shorter hospitalization, and equivalent safety 1, 6
- Perform within 10 days of symptom onset for optimal outcomes 1
- Intraoperative laparoscopic ultrasound has replaced routine cholangiography for CBD stone detection 4
High-Risk or Critically Ill Patients:
- Cholecystostomy (percutaneous or endoscopic drainage) is appropriate for patients with multiple comorbidities or those unfit for surgery 1, 2
- This serves as a temporizing measure or definitive treatment in very high-risk individuals 1
Common Pitfalls to Avoid
- Do not delay surgery beyond 10 days in symptomatic patients—this increases technical difficulty and conversion rates to open surgery 1
- Do not miss concurrent CBD stones—3-10% of cholecystectomy patients have choledocholithiasis, which requires separate management 4
- Recognize biliary injuries early—most complications from laparoscopic cholecystectomy present with immediate postoperative symptoms (pain, fever, jaundice) 7
- Do not perform routine cholecystectomy for truly asymptomatic stones—only 30% will ever require surgery, making prophylactic removal unnecessarily aggressive 4, 3
Role of Medical Therapy
Ursodeoxycholic acid (8-10 mg/kg/day) is NOT appropriate for contracted gallbladders 8. This medication is reserved for:
- Radiolucent stones in functioning gallbladders
- Gallstone prevention during rapid weight loss
- A contracted gallbladder indicates chronic disease requiring surgical intervention, not medical dissolution 8
Algorithm Summary
- Confirm symptomatic status (biliary pain, nausea, RUQ tenderness)
- Ultrasound findings: contracted gallbladder with stones
- Check LFTs and CBD diameter on ultrasound
- If CBD stones suspected: ERCP first, then laparoscopic cholecystectomy 1
- If no CBD involvement: proceed directly to laparoscopic cholecystectomy within 7-10 days 1, 2
- If high surgical risk: consider cholecystostomy 1, 2