What is the management approach for gallbladder cholesterosis?

Gallbladder Cholesterosis Management

Cholecystectomy is the definitive treatment for symptomatic gallbladder cholesterosis, while asymptomatic cases discovered incidentally should be managed expectantly with observation alone. 1

Understanding Cholesterosis

Gallbladder cholesterosis is a benign condition characterized by cholesterol ester deposits in the gallbladder wall, often appearing as a "strawberry gallbladder" on pathology. Importantly, this condition can exist even when cholecystography appears normal, making it a diagnostic challenge. 1

• Cholesterosis may be acalculous (without stones) or occur alongside cholelithiasis 1
• The condition can escape detection by routine imaging, including repeated cholecystography 1
• Patients typically present with symptoms indistinguishable from typical biliary colic—right upper quadrant pain, often postprandial 1

Management Algorithm

For Symptomatic Patients

Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholesterosis, regardless of stone presence. 2, 3

• Surgery should be performed early (within 7 days of symptom onset when feasible) to minimize inflammation and technical difficulty 2
• The Critical View of Safety technique must be achieved during dissection to prevent bile duct injury 2, 3
• Complete symptom resolution occurs in the majority of patients following cholecystectomy for cholesterosis 1

Key surgical considerations:

• Even when no stones are palpable intraoperatively, proceed with cholecystectomy if preoperative diagnosis indicated symptomatic disease 1
• Conversion to open surgery should be considered if Critical View of Safety cannot be achieved rather than persisting with difficult dissection 3
• Intraoperative cholangiography may be performed if anatomy is unclear 3

For Asymptomatic/Incidental Findings

Expectant management with observation is appropriate for asymptomatic cholesterosis discovered incidentally. 4, 2, 5

• The natural history of asymptomatic gallbladder disease is benign, with only 10-25% progressing to symptomatic disease 5
• Most patients who develop complications will first experience at least one episode of biliary pain, providing warning 5
• Routine prophylactic cholecystectomy for asymptomatic findings is not indicated 4, 2

Exceptions requiring prophylactic cholecystectomy:

• Patients undergoing other abdominal surgery where concomitant cholecystectomy adds minimal risk 2
• Presence of large stones (>20mm) or calcified stones alongside cholesterosis 2
• Patients with congenital hemolytic anemia 2

When Cholesterosis Coexists with Cholelithiasis

The management approach depends on stone location and symptoms:

For cholesterosis with gallbladder stones only:

• Standard laparoscopic cholecystectomy as outlined above 2, 3
• No additional interventions required beyond gallbladder removal 2

For cholesterosis with concurrent common bile duct stones:

• Single-session laparoscopic treatment with laparoscopic transcystic CBD exploration (LTCBDE) is preferred when technically feasible 2, 6
• This approach offers shorter hospital stay and equivalent outcomes compared to two-stage procedures 2, 6
• ERCP with sphincterotomy and stone extraction followed by cholecystectomy remains an alternative, particularly when laparoscopic CBD exploration expertise is unavailable 4

Critical Pitfalls and Caveats

Do not dismiss symptoms in patients with normal imaging studies. Cholesterosis can exist despite normal cholecystography, and repeated negative imaging should not preclude surgical evaluation in patients with typical biliary symptoms. 1

Avoid unnecessary surgery in truly asymptomatic patients. The progression rate from asymptomatic to symptomatic disease is relatively low (10-25%), and routine prophylactic cholecystectomy exposes patients to unnecessary surgical risk. 4, 5

Recognize that elderly patients and those with severe comorbidities face significantly higher surgical mortality. Careful risk-benefit assessment is essential in these populations, and conservative management may be more appropriate even for symptomatic disease. 2

Understand that non-surgical therapies have no role in cholesterosis management. Unlike pure cholesterol stones, cholesterosis involves pathologic changes in the gallbladder wall itself. Oral bile acid therapy (ursodeoxycholic acid) and lithotripsy target stone dissolution but cannot reverse cholesterosis. 4, 7, 8

Be aware that symptom recurrence after cholecystectomy for atypical symptoms is more common. Patients with classical biliary pain have better outcomes than those with vague dyspeptic symptoms, though cholesterosis itself typically resolves completely with gallbladder removal. 2, 1