What is the primary treatment for cholelithiasis (gallstones)?

Primary Treatment for Cholelithiasis

Laparoscopic cholecystectomy is the primary treatment for symptomatic cholelithiasis, while asymptomatic gallstones require only observation unless specific high-risk features are present. 1

Treatment Algorithm Based on Symptom Status

Symptomatic Cholelithiasis

Laparoscopic cholecystectomy is the definitive first-line treatment for all patients with symptomatic gallstones. 1 This approach provides immediate and permanent stone removal with superior outcomes compared to conservative management. 1

Timing of surgery:

• Early cholecystectomy (within 7-10 days of symptom onset) is recommended for acute calculous cholecystitis, as it results in shorter recovery time and hospitalization compared to delayed surgery. 2, 1
• For patients presenting beyond 10 days of symptoms, delayed cholecystectomy after 45 days is preferable unless worsening peritonitis or sepsis develops. 2
• For mild gallstone pancreatitis, perform cholecystectomy within 2-4 weeks to prevent recurrent attacks. 1

Surgical approach:

• Laparoscopic cholecystectomy has become the therapy of choice, with success rates exceeding 97%. 1, 3
• The procedure should utilize the Critical View of Safety technique to minimize bile duct injury risk (0.4-1.5%). 1, 4
• Conversion to open surgery should be considered when severe local inflammation obscures anatomy or bile duct injury is suspected. 1
• Subtotal cholecystectomy is appropriate for gangrenous gallbladder or "difficult gallbladder" where anatomy cannot be safely identified. 1

Clinical outcomes:

• Mortality for low-risk women under 49 years is 0.054%, increasing with age and comorbidities. 1
• Men have approximately twice the surgical mortality rate of women. 1
• 87% of patients are discharged by the first postoperative day, with most resuming normal activities within 1 week. 3
• 36% of patients require no narcotics after leaving the recovery room. 3

Asymptomatic Cholelithiasis

Expectant management is recommended for the vast majority of asymptomatic patients, as approximately 80% remain asymptomatic throughout their lives with only 2% per year developing symptoms. 5

Prophylactic cholecystectomy is indicated only for:

• Gallstones larger than 3 cm in diameter (significantly elevated gallbladder cancer risk). 1, 5
• Calcified "porcelain" gallbladder (malignancy risk). 1, 5
• Native Americans, particularly Pima Indians and other New World Indians (substantially elevated gallbladder cancer risk). 1, 5
• Gallstone ileus. 1

Diabetes mellitus alone is NOT an indication for prophylactic cholecystectomy. 5

Alternative Management Options (Limited Role)

For Poor Surgical Candidates

Percutaneous cholecystostomy may be performed as a safe treatment in critically ill patients or those with multiple comorbidities unfit for surgery who fail antibiotic therapy. 2, 1 However, cholecystostomy is inferior to cholecystectomy in terms of major complications and should only serve as a bridge to definitive surgery when patients may become suitable after stabilization. 1

Non-Surgical Therapies (Rarely Appropriate)

Non-surgical options should only be considered for patients who refuse surgery or are poor surgical candidates, and are highly limited by stone characteristics:

• Oral bile acids (ursodeoxycholic acid): Most effective only for stones <0.5 cm that are radiolucent (cholesterol-rich) with patent cystic duct. 1
• Extracorporeal shock-wave lithotripsy: Effective only for solitary radiolucent stones <2 cm, used with adjuvant oral bile acids. 1
• Direct contact dissolution (methyl-tert-butyl-ether): Remains investigational and inappropriate for most cases. 1

Critical limitation: All non-surgical therapies fail to prevent gallstone recurrence or reduce gallbladder cancer risk. 1

Special Populations

Pregnancy

• Laparoscopic cholecystectomy is safe during any trimester but ideally performed in the second trimester. 1
• Conservative management has a 60% recurrence rate of biliary symptoms. 1
• Same-admission cholecystectomy for acute biliary pancreatitis reduces early readmission by 85%. 1

Elderly Patients

• Age alone is NOT a contraindication to cholecystectomy. 1
• Laparoscopic cholecystectomy is preferred even in elderly patients, with lower 2-year mortality compared to nonoperative management. 1

Cirrhotic Patients

• Laparoscopic cholecystectomy is first choice for Child-Pugh A and B cirrhosis. 1
• Child-Pugh C or uncompensated cirrhosis patients should avoid cholecystectomy unless clearly indicated. 1

Diagnostic Evaluation

Ultrasound is the investigation of choice for suspected acute cholecystitis due to low cost, lack of invasiveness, no radiation exposure, better availability, and high accuracy for gallbladder stones. 2, 1 Typical findings include pericholecystic fluid, distended gallbladder, edematous gallbladder wall, gallstones, and positive Murphy's sign on ultrasound examination. 2

MRCP (magnetic resonance cholangiopancreatography) is recommended for patients with suspected common bile duct stones, particularly if liver enzymes or bilirubin are elevated. 1

Antibiotic Therapy

• One-shot prophylaxis is recommended for uncomplicated cholecystitis with early intervention, with no post-operative antibiotics needed. 1
• Antibiotic therapy for 4 days is recommended for complicated cholecystitis in immunocompetent non-critically ill patients if source control is adequate. 1
• Antibiotic therapy up to 7 days may be necessary for immunocompromised or critically ill patients. 1

Common Pitfalls

• Ambiguous or atypical symptoms (indigestion, flatulence, heartburn, bloating, belching, nausea) are less likely to resolve following cholecystectomy. 1 Surgery should be reserved for patients with true biliary colic.
• CCK-cholescintigraphy does not add to clinical judgment in predicting surgical outcomes for patients with atypical symptoms. 1, 5
• Delaying cholecystectomy in mild gallstone pancreatitis beyond 4 weeks increases risk of recurrent attacks. 1
• Approximately 30% of patients with a single episode of biliary pain may not experience additional episodes, but surgery remains indicated for symptomatic disease. 1
• Surgeon experience is critical—bile duct injury occurs in 0.4-1.5% of cases, emphasizing the importance of adequate training and maintaining a low threshold for conversion to open surgery when anatomy is uncertain. 1, 4