From the Guidelines
Incidental gallstones that are asymptomatic should be managed with expectant management, as the risks of surgical and nonsurgical intervention still outweigh their corresponding benefits. This approach is recommended for patients with asymptomatic gallstones, regardless of age or sex, as they have a low risk of incurring major complications 1. The effort and minor risks of surgical and nonsurgical intervention are not justified, given the benign history and low risk of complications.
Key Considerations
- Patients with a high risk for gallbladder cancer, such as those with calcified gallbladders or large (> 3 cm) stones, may be exceptions to this recommendation and may benefit from prophylactic cholecystectomy 1.
- Patients should be educated about potential symptoms of biliary colic and advised to seek medical attention if such symptoms develop.
- Lifestyle modifications, such as maintaining a healthy weight and avoiding rapid weight loss, may help prevent symptom development.
Treatment Approach
- If symptoms do develop, laparoscopic cholecystectomy becomes the standard treatment.
- Medical dissolution therapy with ursodeoxycholic acid is rarely used due to limited efficacy and high recurrence rates.
- The conservative approach for asymptomatic gallstones is justified because many patients will never develop symptoms, and the risks of surgery generally outweigh the benefits in asymptomatic individuals 1.
From the Research
Incidental Gallstones Management
- The management of incidental gallstones is a topic of debate, with some studies suggesting that asymptomatic gallstones do not require treatment 2, 3.
- However, certain sub-groups of patients, such as those with chronic hemolytic syndromes, may be at a higher risk of developing symptoms and complications, and prophylactic cholecystectomy may be advised for them 2.
- Laparoscopic cholecystectomy is a safe procedure, but it carries a higher risk of bile duct injury compared to open cholecystectomy, which should be considered before offering prophylactic cholecystectomy to asymptomatic patients 2.
- The natural history of asymptomatic gallstones suggests that a large majority of patients will remain asymptomatic, but diabetics and patients whose stones are detected initially at laparotomy are at increased risk of developing symptoms 3.
- Current guidelines do not recommend cholecystectomy unless gallstones cause symptoms, and laparoscopic cholecystectomy is the standard treatment for symptomatic gallstones, acute cholecystitis, and gallstone pancreatitis 4.
- Ursodeoxycholic acid (UDCA) may be a promising option for reducing the need for cholecystectomy in patients with post-laparoscopic sleeve gastrectomy gallstones, but it appears ineffective for pre-existing gallstones 5.
- The incidence of gallstone-related complications is approximately 1% per year in asymptomatic patients and 2% per year in patients who already have symptoms, and cholecystectomy remains the procedure of choice for patients with recurrent or complicated gallstone symptoms 6.