What is the recommended management for a patient with suspected gallstones, considering their overall health status and potential complications?

Management of Gallstones: Evidence-Based Approach

Primary Recommendation

Patients with confirmed gallstones should undergo active stone extraction rather than medical dissolution therapy, with the specific approach determined by stone location: laparoscopic cholecystectomy for symptomatic gallbladder stones (performed within 7-10 days of symptom onset), and ERCP with stone extraction for common bile duct stones. 1, 2

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Initial Diagnostic Workup

For suspected gallstones, obtain trans-abdominal ultrasound and liver function tests as first-line investigations. 3 Normal results do not exclude the diagnosis if clinical suspicion remains high. 3

Key Clinical Features to Assess:

• Biliary colic pattern: Severe, steady pain lasting >15 minutes in the right upper quadrant or epigastrium, unaffected by position, often postprandial 2
• Complications indicators: Fever, jaundice, Murphy's sign, persistent pain >6 hours (suggesting cholecystitis, cholangitis, or pancreatitis) 4
• Laboratory markers: Elevated bilirubin, alkaline phosphatase, and GGT suggest bile duct obstruction; leukocytosis indicates infection 4

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Treatment Algorithm by Stone Location

Gallbladder Stones (Symptomatic)

Perform early laparoscopic cholecystectomy within 7-10 days of symptom onset. 2 This approach:

• Achieves >97% success rate with immediate, permanent stone removal 2
• Shortens total hospital stay by approximately 4 days compared to delayed surgery 2
• Allows return to work approximately 9 days sooner 2
• Prevents recurrent attacks and complications that occur in ~30% of patients managed conservatively 2

Pre-operative considerations:

• Obtain MRCP if common bile duct stones are suspected 2
• Initiate antibiotics for acute cholecystitis with systemic illness: one-shot prophylaxis for early intervention, 4 days if adequate source control achieved, up to 7 days for immunocompromised patients 2

Common Bile Duct Stones (CBDS)

Offer stone extraction to all patients with confirmed CBDS, as untreated stones result in unfavorable outcomes (pancreatitis, cholangitis, obstruction) in 25.3% versus 12.7% with planned extraction. 3, 2

Two equally valid approaches:

1. ERCP with stone extraction (primary approach):

   • Administer rectal NSAIDs (100 mg indomethacin or diclofenac) at time of ERCP to reduce post-ERCP pancreatitis risk 1
   • Perform with propofol sedation or general anesthesia for optimal success rates 3, 1
   • Check FBC and INR/PT before biliary sphincterotomy 1
   • In patients with high risk of post-ERCP pancreatitis from repeated pancreatic duct cannulation, insert pancreatic stent in addition to rectal NSAID 3

2. Laparoscopic bile duct exploration (LBDE) during cholecystectomy:

   • No difference in efficacy, mortality, or morbidity compared to ERCP 3, 1
   • Associated with shorter hospital stay 3, 1
   • Can be performed transcystic or transductal 3

Critical: If ERCP clears CBD stones but gallbladder stones remain, cholecystectomy must still be performed, as recurrent biliary events occur significantly more frequently without cholecystectomy. 2

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When Medical Dissolution Therapy is NOT Appropriate

Ursodiol is contraindicated in patients with acute cholestasis, common bile duct obstruction, or non-functioning gallbladder—all common features of symptomatic gallstone disease. 1, 5

Delaying definitive stone extraction by attempting medical dissolution increases risk of complications including cholangitis, pancreatitis, and hepatic dysfunction. 1

Limited Role of Ursodiol:

Medical dissolution with ursodiol (8-10 mg/kg/day) achieves complete dissolution in only ~30% of highly selected patients with uncalcified stones <20 mm treated for up to 2 years. 5 Stone recurrence occurs in up to 50% within 5 years after successful dissolution. 5, 6 This approach is reserved only for patients who absolutely cannot undergo surgery and have radiolucent stones with patent cystic duct. 6, 7, 8

The only established role for ursodiol is prevention of gallstone formation during rapid weight loss (bariatric surgery or very low calorie diet), where it reduces stone formation from 23% to 2-6%. 5, 9

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High-Risk Surgical Candidates

For patients with multiple comorbidities truly unfit for surgery who fail antibiotic therapy, percutaneous cholecystostomy may be considered, though this is clearly inferior to cholecystectomy. 2

Surgical mortality varies significantly by patient characteristics (see FDA data): women aged 0-49 in good health have lowest mortality (0.54 per 1,000 operations), while rates increase tenfold with severe systemic disease and quadruple with common duct exploration. 5

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Critical Pitfalls to Avoid

• Do not delay surgery in symptomatic patients: While ~30% with single episode may not have recurrence, patients with frequent symptoms are past this point and require intervention 2
• Do not attempt medical dissolution for CBD stones: This increases complication risk and delays definitive treatment 1
• Do not omit cholecystectomy after CBD clearance if gallbladder stones remain: Recurrent biliary events will occur 2
• Do not assume normal ultrasound and LFTs exclude CBDS if clinical suspicion is high: Further investigation is warranted 3
• Do not perform ERCP without rectal NSAIDs: This simple intervention significantly reduces post-ERCP pancreatitis 1