What is the treatment for gallstones?

Treatment for Gallstones

Laparoscopic cholecystectomy is the definitive treatment for symptomatic gallstones of any size and should be performed early (within 7-10 days of symptom onset for acute cholecystitis) to prevent recurrent pain, complications, and eliminate gallbladder cancer risk. 1, 2

Treatment Algorithm Based on Symptom Status

Symptomatic Gallstones

• Laparoscopic cholecystectomy is the treatment of choice regardless of stone size 1, 2
• Success rates exceed 97% even in complicated cases 1
• For acute calculous cholecystitis, perform surgery within 7 days of hospital admission and 10 days from symptom onset 2
• For acute gallstone pancreatitis, perform same-admission cholecystectomy once clinically improving, as early as the second hospital day for mild cases 2
• Recovery time is 1-2 weeks versus several months for open surgery 1
• Mortality for low-risk women under 49 years is 0.054%, with rates doubling for men 1, 3

Asymptomatic Gallstones

• Expectant management is recommended for most asymptomatic patients 2, 4
• Only 30% will require surgery during their lifetime 4
• Exception: Prophylactic cholecystectomy is indicated for stones >3 cm due to increased gallbladder cancer risk 1, 4
• Other high-risk features warranting prophylactic surgery include calcified gallbladders and certain ethnic populations (e.g., Pima Indians) 1, 2

Non-Surgical Options (Limited Role)

Non-surgical therapies are inferior to cholecystectomy and reserved only for patients who are poor surgical candidates or refuse surgery 2, 5. These options have significant limitations:

Oral Bile Acid Therapy (Ursodeoxycholic Acid)

• Restricted to stones <5-6 mm diameter that are radiolucent and float on oral cholecystography 1, 4, 5
• Dosing: 8-10 mg/kg/day in 2-3 divided doses 3
• Requires months of therapy with only 75% annual dissolution rate in carefully selected patients 5
• Stone recurrence occurs in up to 50% of patients within 5 years 1, 3
• Does not prevent gallbladder cancer 1, 4

Extracorporeal Shock-Wave Lithotripsy

• Best for solitary radiolucent stones <2 cm with adjuvant oral bile acids 1, 4
• Annual dissolution rates are 80% for single stones and 40% for multiple stones 5
• Still carries 50% recurrence rate 1

Direct Contact Dissolution (Methyl-tert-butyl-ether)

• Can dissolve stones of any size and number 2, 5
• Remains investigational 2
• Nearly 100% dissolution but frequently leaves debris 5

Common Bile Duct Stones

• ERCP with endoscopic sphincterotomy achieves 90% success rate for most CBD stones 1
• Stones >10-15 mm typically require lithotripsy or fragmentation during ERCP 1, 4
• Urgent ERCP is indicated for severe gallstone pancreatitis failing to improve within 48 hours, biliary obstruction, or biliary sepsis 2

Special Populations

Pregnancy

• Laparoscopic cholecystectomy is safe during any trimester but ideally performed in the second trimester 2
• Conservative management has 60% recurrence rate of biliary symptoms 2
• Same-admission cholecystectomy for acute biliary pancreatitis reduces early readmission by 85% 2

Elderly and High-Risk Patients

• Age alone is NOT a contraindication to cholecystectomy 2
• Laparoscopic cholecystectomy has lower 2-year mortality compared to nonoperative management even in elderly patients 2
• Percutaneous cholecystostomy may be considered for patients truly unfit for surgery, but is inferior to cholecystectomy with significantly more major complications (53% vs 5%) 2

Cirrhotic Patients

• Laparoscopic cholecystectomy is first choice for Child-Pugh A and B 2
• Child-Pugh C or uncompensated cirrhosis patients should avoid cholecystectomy unless clearly indicated 2

Critical Technical Considerations

• Critical View of Safety technique must be employed to minimize bile duct injury risk (0.4-1.5%) 1, 4
• Surgeon experience is crucial, particularly for large or impacted stones 1
• Conversion to open surgery is not a failure but a valid option when laparoscopic expertise has been maximized 2
• Subtotal cholecystectomy is appropriate for advanced inflammation or "difficult gallbladder" where anatomy is difficult to recognize 2

Antibiotic Therapy

• One-shot prophylaxis for uncomplicated cholecystitis with early intervention, no post-operative antibiotics 2
• 4 days of antibiotics for complicated cholecystitis in immunocompetent non-critically ill patients if source control is adequate 2
• Up to 7 days may be necessary for immunocompromised or critically ill patients 2

Critical Pitfalls to Avoid

• Do not attempt non-surgical therapy for stones >2-2.7 cm—these exceed size limits for all medical treatments and only delay definitive management 1, 4
• Do not use "watchful waiting" for large (>3 cm) asymptomatic stones due to gallbladder cancer risk 1, 4
• Ambiguous symptoms (indigestion, flatulence, heartburn, bloating) are less likely to resolve following cholecystectomy 2
• Delaying cholecystectomy in mild gallstone pancreatitis beyond 4 weeks increases risk of recurrent attacks 2
• Recognize that non-surgical therapies neither prevent stone recurrence nor eliminate gallbladder cancer risk 1, 4