What is the treatment for cholelithiasis?

Treatment of Cholelithiasis

For symptomatic cholelithiasis, laparoscopic cholecystectomy is the definitive treatment of choice, while asymptomatic gallstones require only expectant management unless high-risk features are present. 1

Asymptomatic Cholelithiasis

Expectant management is recommended for asymptomatic gallstones due to the benign natural history—approximately 80% of patients remain asymptomatic throughout their lives with low progression rates to complications. 2

Exceptions Requiring Prophylactic Cholecystectomy:

• Calcified ("porcelain") gallbladder (high gallbladder cancer risk) 1
• New World Indians (e.g., Pima Indians) with elevated cancer risk 1
• Stones >3 cm (increased malignancy risk) 1
• Incidental finding during other abdominal surgery 2

CCK-cholescintigraphy has no role in predicting which asymptomatic patients will develop symptoms and should not be used for risk stratification. 2

Symptomatic Cholelithiasis

Primary Surgical Approach

Laparoscopic cholecystectomy is the first-line treatment for all symptomatic gallstones regardless of stone size, offering immediate and permanent stone removal. 1, 3

Timing considerations:

• Uncomplicated symptomatic disease: Elective laparoscopic cholecystectomy at patient convenience 1
• Acute calculous cholecystitis: Early laparoscopic cholecystectomy within 7-10 days of symptom onset results in shorter recovery time and hospitalization compared to delayed surgery 2, 1
• Symptoms >10 days duration: Delayed cholecystectomy after 45 days is preferable unless worsening peritonitis or sepsis develops 2

Surgical mortality varies by patient factors:

• Low-risk women <49 years: 0.054% mortality 1
• Men have approximately twice the surgical mortality of women 1
• Mortality increases with age and systemic comorbidities 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 For pregnant patients with acute biliary pancreatitis, same-admission cholecystectomy reduces early readmission by 85%. 1

Elderly patients: Age alone is NOT a contraindication—laparoscopic cholecystectomy has lower 2-year mortality compared to nonoperative management even in elderly patients. 1

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

Critically ill or high-risk surgical candidates: Percutaneous cholecystostomy is reserved for patients truly unfit for surgery, though it is inferior to cholecystectomy in terms of major complications. 2, 1 It can serve as a bridge to definitive surgery after stabilization. 1

Antibiotic Therapy

Uncomplicated cholecystitis: One-shot prophylactic antibiotics with no post-operative therapy if source control is complete and early intervention performed. 2, 1

Complicated cholecystitis in immunocompetent patients: 4 days of antibiotic therapy if source control is adequate. 1

Immunocompromised or critically ill patients: Up to 7 days of antibiotics based on clinical conditions and inflammation indices. 1

Non-Surgical Options (Limited Role)

Non-surgical therapies are reserved for highly select patients who refuse surgery or are poor surgical candidates, with important limitations:

Oral Bile Acid Therapy (Ursodeoxycholic Acid)

FDA-approved dosing: 8-10 mg/kg/day in 2-3 divided doses for gallstone dissolution. 4

Strict patient selection criteria:

• Small stones (<6 mm, ideally <5 mm) 1, 4, 5
• Radiolucent (cholesterol-rich) stones that float on oral cholecystography 1, 5
• Patent cystic duct 1
• Patients unfit for or refusing surgery 1

Monitoring: Ultrasound at 6-month intervals for the first year; if partial dissolution not seen by 12 months, likelihood of success is greatly reduced. 4

Major limitation: Does not reduce gallbladder cancer risk and stones frequently recur after discontinuation. 1

Other Non-Surgical Modalities

Extracorporeal shock-wave lithotripsy (ESWL): Most effective for solitary radiolucent stones <2 cm, used with adjuvant oral bile acids. 1, 5 Limited availability and high recurrence rates restrict its use. 6

Direct contact dissolution (methyl-tert-butyl-ether): Still investigational; can dissolve stones of any size but not widely available. 1, 5

Cholelithiasis with Choledocholithiasis

For concurrent common bile duct stones (present in 10-20% of gallstone patients): 3, 7

Preferred approach: Laparoscopic cholecystectomy with intraoperative ERCP/ES or laparoscopic common bile duct exploration offers one-session treatment with shorter hospital stay and cost benefits compared to sequential approaches. 3, 7

Alternative sequential approach: Preoperative ERCP/ES followed by laparoscopic cholecystectomy, though this has higher morbidity (16% post-ERCP pancreatitis rate) and frequent negative ERCP findings. 3

For severe gallstone pancreatitis: ERCP urgently if patient fails to improve within 48 hours despite intensive resuscitation, or if biliary obstruction/sepsis present. 1 For mild gallstone pancreatitis, perform cholecystectomy within 2-4 weeks. 1

Diagnostic Evaluation

Ultrasound is the investigation of choice for suspected acute cholecystitis, showing pericholecystic fluid, distended gallbladder, edematous wall, gallstones, and positive sonographic Murphy's sign. 2, 1

CT with IV contrast may be used as an alternative. 1

MRCP is recommended for patients with suspected common bile duct stones. 1

Critical Pitfalls to Avoid

Atypical symptoms (indigestion, flatulence, heartburn, bloating, belching, nausea) are less likely to resolve following cholecystectomy compared to classic biliary pain. 2, 1 CCK-cholescintigraphy does not add to clinical judgment in predicting surgical outcomes for these patients. 2, 1

Bile duct injury is a potential complication of laparoscopic cholecystectomy—ensure surgeon is appropriately qualified and experienced. 1 Conversion to open surgery should be considered in cases of severe local inflammation or suspected bile duct injury. 1

Subtotal cholecystectomy is a valid option for advanced inflammation, gangrenous gallbladder, or "difficult gallbladder" where anatomy is difficult to recognize and bile duct injuries are highly probable. 1