What is the diagnosis and treatment for Cholelithiasis (Gallstones)?

From the Guidelines

Cholecystectomy is the preferred treatment for symptomatic cholelithiasis, and laparoscopic approach should always be attempted at first, except in case of absolute anesthetic contraindications and septic shock, as it is safe, feasible, with a low complication rate, and associated with shortened hospital stay 1.

Diagnosis and Treatment

For symptomatic cholelithiasis, diagnosis can be made using a combination of symptoms, signs, and laboratory tests, as no single investigation has sufficient diagnostic power to establish or exclude acute cholecystitis 1. Abdominal ultrasound is the preferred initial imaging technique, especially in elderly patients, due to its lower costs, better availability, lack of invasiveness, and good accuracy for stones 1.

Surgical Approach

The evaluation of the risk for elderly patients with cholelithiasis should include mortality rate for conservative and surgical therapeutic options, rate of gallstone-related disease relapse, age-related life expectancy, and patient frailty evaluation by the use of frailty scores 1.

Alternative Treatments

Percutaneous cholecystostomy can be considered in the treatment of acute cholecystitis patients who are deemed unfit for surgery, and it should be removed between 4 and 6 weeks after placement, if a cholangiogram performed 2–3 weeks after percutaneous cholecystostomy demonstrated biliary tree patency 1.

Common Bile Duct Stones

Elevation of liver biochemical enzymes and/or bilirubin levels is not sufficient to identify patients with choledocholithiasis, and further diagnostic tests are needed, such as liver biochemical tests, including ALT, AST, bilirubin, ALP, GGT, and abdominal ultrasound 1. Some key points to consider in the management of cholelithiasis include:

• Cholecystectomy is the preferred treatment for symptomatic cholelithiasis 1
• Laparoscopic approach should always be attempted at first, except in case of absolute anesthetic contraindications and septic shock 1
• Abdominal ultrasound is the preferred initial imaging technique, especially in elderly patients 1
• Percutaneous cholecystostomy can be considered in the treatment of acute cholecystitis patients who are deemed unfit for surgery 1
• Elevation of liver biochemical enzymes and/or bilirubin levels is not sufficient to identify patients with choledocholithiasis, and further diagnostic tests are needed 1

From the Research

Definition and Prevalence of Cholelithiasis

• Cholelithiasis, or gallstone disease, is a common clinical problem with a wide range of clinical presentations, from asymptomatic to recurrent attacks of biliary pain 2.
• The presence of bile duct stones is a frequent condition associated with cholelithiasis, occurring in 5%-15% of total cholecystectomies performed every year 2.

Management Strategies for Cholelithiasis

• The management of cholelithiasis with choledocholithiasis has become multidisciplinary, with various therapeutic choices available, including endoscopic, radiologic, and minimally invasive surgical techniques 2.
• A comparison of two-session and one-session treatment approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay and more cost benefits 2.
• Laparoscopic cholecystectomy (LC) with intraoperative cholangiography (IOC) ± common bile duct exploration (CBDE) is considered the most cost-effective treatment strategy for patients with symptomatic cholelithiasis and possible common bile duct stones 3.

Treatment Guidelines for Symptomatic Gallstone Disease

• The Danish Surgical Society recommends acute laparoscopic cholecystectomy for patients with acute cholecystitis, and a one-step procedure with simultaneous laparoscopic cholecystectomy and common bile duct stone removal by laparoscopy or endoscopy for patients with common bile duct stones 4.
• For patients with uncomplicated symptomatic gallstone disease, observation is suggested as an alternative to laparoscopic cholecystectomy 4.
• A systematic review of treatment options for symptomatic cholelithiasis highlights the need for standardized guidelines and suggests that future trials should guide comparisons between the timing of surgery and watchful waiting 5.

Evolving Intraoperative Strategies for Choledocholithiasis

• The approach to choledocholithiasis has evolved with the advent of laparoscopic cholecystectomy, and various techniques are now available, including transcystic extraction, direct laparoscopic choledocholithotomy, and intraoperative endoscopic retrograde cholangiopancreatography 6.
• Preoperative endoscopic retrograde cholangiopancreatography is no longer necessary in many cases, and the choice of approach depends on the individual patient's situation and the surgeon's expertise 6.