What are the treatment options for cholelithiasis (gallstones)?

From the Guidelines

Gallstone treatment depends on whether symptoms are present, with surgical removal of the gallbladder (cholecystectomy) being the standard treatment for symptomatic gallstones, as recommended by the American College of Physicians 1, 2, 3, 4, 5, 6, 7, 8, 9, 10. For asymptomatic gallstones, typically no treatment is needed as they often cause no problems. However, for symptomatic gallstones causing pain or complications, the choice of treatment proves more complicated, and the following recommendations are suggested:

• The clinician should determine if the biliary pain is the first episode and whether the pain indicates gallstone disease.
• The clinician should assess the patient's treatment goals and attitudes, specifically determining whether the patient wants to prevent another episode of pain.
• If the patient primarily wants to reduce the risk for death from gallstones and if the pain is a first episode, then the patient may choose to observe the pattern of pain before deciding about therapy. Some key points to consider include:
• Patients with a high risk for gallbladder cancer, for whom prophylactic cholecystectomy may be advisable, are exceptions to the recommendation for expectant management of asymptomatic gallstones.
• The potential problem of bile duct injury should be considered, especially for laparoscopic cholecystectomy.
• Nonsurgical methods, such as oral dissolution therapy with ursodeoxycholic acid or extracorporeal shock wave lithotripsy, may be considered if the patient is a good candidate. While waiting for surgery, pain can be managed with medications like ibuprofen (400-600mg every 6 hours) or acetaminophen (500-1000mg every 6 hours) 1, 2, 3, 4, 5, 6, 7, 8, 9, 10. In cases where surgery isn't possible, non-surgical options may be used, though recurrence is common. Dietary changes like reducing fat intake and maintaining a healthy weight can help manage symptoms but won't eliminate existing stones. Gallstones form when bile components crystallize, typically from excess cholesterol or bilirubin, or when the gallbladder doesn't empty properly, making surgical removal the most effective long-term solution for symptomatic cases.

From the FDA Drug Label

ALTERNATIVE THERAPIES Watchful Waiting Watchful waiting has the advantage that no therapy may ever be required. For patients with silent or minimally symptomatic stones, the rate of development of moderate-to-severe symptoms or gallstone complications is estimated to be between 2% and 6% per year, leading to a cumulative rate of 7% to 27% in 5 years Presumably the rate is higher for patients already having symptoms. Cholecystectomy For patients with symptomatic gallstones, surgery offers the advantage of immediate and permanent stone removal, but carries a high risk in some patients. SPECIAL NOTE Gallbladder stone dissolution with Ursodiol Capsules USP, 300 mg treatment requires months of therapy. Complete dissolution does not occur in all patients and recurrence of stones within 5 years has been observed in up to 50% of patients who do dissolve their stones on bile acid therapy. Patients should be carefully selected for therapy with ursodiol, and alternative therapies should be considered.

Treatment options for gallstones include:

• Watchful waiting, which may be suitable for patients with silent or minimally symptomatic stones
• Cholecystectomy, which offers immediate and permanent stone removal but carries a high risk in some patients
• Ursodeoxycholic acid (ursodiol) therapy, which can dissolve gallbladder stones but requires months of treatment and has a recurrence rate of up to 50% within 5 years [11] [12]. The choice of treatment should be based on careful selection of patients and consideration of alternative therapies.

From the Research

Treatment Options for Gallstones

• Laparoscopic cholecystectomy is considered the gold standard for treating symptomatic gallstones 13, 14, 15
• Alternative treatment modalities, such as ursodeoxycholic acid (UDCA), may be considered for high-risk patients or those who reject surgery 13, 16
• For patients with acute cholecystitis, acute laparoscopic cholecystectomy is recommended 17
• Gallbladder drainage may be used as an interval procedure before a delayed laparoscopic cholecystectomy in patients with temporary contraindications to surgery and severe acute cholecystitis 17
• For patients with common bile duct stones (CBDS), a one-step procedure with simultaneous laparoscopic cholecystectomy and CBDS removal by laparoscopy or endoscopy is recommended 17, 14

Recommendations for Specific Patient Groups

• High-risk patients are suggested to undergo acute laparoscopic cholecystectomy instead of drainage 17
• For patients with CBDS, laparoscopic cholecystectomy is suggested to be included in the treatment 17
• For patients with uncomplicated symptomatic gallstone disease, observation is suggested as an alternative to laparoscopic cholecystectomy 17

Use of Ursodeoxycholic Acid (UDCA)

• UDCA is a bile acid that dissolves gallstones and may be used in the management of symptomatic gallstone disease, particularly in those unfit for surgery 16
• However, evidence for UDCA in symptomatic gallstones is scarce and heterogenous, and level 1 evidence is required to support its use in the future 16