What is the recommended treatment for a patient with a distended gallbladder containing stones?

Treatment of Gallbladder with Stones

Laparoscopic cholecystectomy should be performed early (within 7-10 days of symptom onset) for symptomatic gallstones, and is the definitive treatment that prevents recurrent biliary complications and reduces mortality compared to conservative management. 1, 2, 3

Clinical Decision Algorithm

For Symptomatic Gallstones (Biliary Colic, Acute Cholecystitis)

Primary Treatment:

• Early laparoscopic cholecystectomy is the gold standard and should be performed within 7 days of hospital admission and 10 days of symptom onset for acute cholecystitis 1, 2, 3
• One-shot antibiotic prophylaxis is given if early intervention occurs, with no post-operative antibiotics needed for uncomplicated cases 1, 3
• This approach shortens total hospital stay by approximately 4 days and allows return to work 9 days sooner compared to delayed surgery 3

Imaging Workup:

• Ultrasound is the investigation of choice, looking for gallstones, distended gallbladder, edematous gallbladder wall, pericholecystic fluid, and Murphy's sign 1
• CT with IV contrast can be used as an alternative 1
• MRCP should be obtained if common bile duct stones are suspected 1

For Complicated Cholecystitis

Surgical Management:

• Laparoscopic cholecystectomy remains first-line, with open cholecystectomy as an alternative 1
• Antibiotic therapy for 4 days post-operatively in immunocompetent, non-critically ill patients if source control is adequate 1, 3
• Antibiotic therapy up to 7 days for immunocompromised or critically ill patients based on clinical conditions and inflammation indices 1, 3

Alternative for High-Risk Patients:

• Percutaneous cholecystostomy may be considered for patients with multiple comorbidities who are truly unfit for surgery (ASA III/IV, performance status 3-4) and do not improve with antibiotic therapy after several days 1, 3
• Critical caveat: Cholecystostomy is inferior to cholecystectomy with significantly more major complications (53% vs 5%) in critically ill patients 1, 3

For Gallbladder Stones with Common Bile Duct Stones

This scenario requires a two-pronged approach:

1. ERCP for duct clearance (if stones are present in the common bile duct) 1, 2
2. Followed by cholecystectomy - this is mandatory and strongly recommended 1

Evidence supporting cholecystectomy after duct clearance:

• Meta-analysis of 5 randomized trials (662 participants) showed mortality was significantly higher in the "wait and see" group versus prophylactic cholecystectomy group (14.1% vs 7.9%; RR 1.78,95% CI 1.15-2.75) over follow-up periods ranging from 17 months to 5+ years 1
• Recurrent pain, jaundice, and cholangitis were significantly more common without cholecystectomy 1
• The benefit of surgery persisted even in patients at higher surgical risk (ASA 4 or 5) 1

Exception: Surgeons may discuss a "wait and see" approach only for patients with an empty gallbladder after duct clearance, as recurrent CBD stones occur in only 5.9-11.3% versus 15-23.7% in patients with residual gallbladder stones 1

For Asymptomatic Gallstones

Expectant management is recommended for most patients with asymptomatic gallstones due to low risk of complications 3

Exceptions requiring prophylactic cholecystectomy:

• Gallstones larger than 3 cm (elevated gallbladder cancer risk) 4
• Calcified gallbladder 3, 4
• High-risk ethnic populations (e.g., New World Indians/Pima Indians) 3, 4

Special Populations

Pregnant Patients:

• Laparoscopic cholecystectomy is safe during any trimester but ideally performed in the second trimester 3
• Conservative management has a 60% recurrence rate of biliary symptoms 3
• Same-admission cholecystectomy for acute biliary pancreatitis reduces early readmission by 85% 3

Elderly Patients:

• Age alone is NOT a contraindication to cholecystectomy 3
• Laparoscopic cholecystectomy is preferred even in elderly patients, with lower 2-year mortality compared to nonoperative management 3

Cirrhotic Patients:

• Laparoscopic cholecystectomy is first choice for Child-Pugh A and B 3
• Child-Pugh C or uncompensated cirrhosis patients should avoid cholecystectomy unless clearly indicated 3

Technical Considerations

• The "Critical View of Safety" technique should be employed during laparoscopic cholecystectomy to minimize bile duct injury risk (0.4-1.5%) 2, 4
• Conversion to open surgery is not a failure but a valid option when laparoscopic expertise has been maximized, particularly with severe local inflammation or suspected bile duct injury 3
• Subtotal cholecystectomy is valid for advanced inflammation, gangrenous gallbladder, or "difficult gallbladder" where anatomy is difficult to recognize 3

Common Pitfalls to Avoid

• Do not delay surgery beyond 7-10 days in acute cholecystitis, as this increases complications and conversion rates 1, 2, 3
• Do not leave the gallbladder in situ after CBD stone clearance if gallbladder stones remain, as this significantly increases mortality and recurrent biliary events 1
• Do not rely on cholecystostomy as definitive treatment in patients who could tolerate surgery, as outcomes are significantly worse 1, 3
• Patients with ongoing signs of infection or systemic illness beyond 7 days of antibiotic treatment warrant diagnostic investigation 1