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Gallstones(Cholelithiasis)Treatment&Management:ApproachConsiderations,TreatmentofAsymptomaticGallstones,TreatmentofPatientwit

Gallstones(Cholelithiasis)Treatment&Management
Author:DouglasMHeuman,MD,FACP,FACG,AGAFChiefEditor:JulianKatz,MDmore...
Updated:Jan20,2015

ApproachConsiderations
Thetreatmentofgallstonesdependsuponthestageofdisease.Ideally,
interventionsinthelithogenicstatecouldpreventgallstoneformation,although,
currently,thisoptionislimitedtoafewspecialcircumstances.Asymptomatic
gallstonesmaybemanagedexpectantly.
Oncegallstonesbecomesymptomatic,definitivesurgicalinterventionwith
cholecystectomyisusuallyindicated,although,insomecases,medicaldissolution
maybeconsidered.Inuncomplicatedcholelithiasiswithbiliarycolic,medical
managementmaybeausefulalternativetocholecystectomyinselectedpatients,
particularlythoseforwhomsurgerywouldposehighrisk.Medicaltreatment,beyond
paincontrol,isnotinitiatedintheemergencydepartment.
Medicaltreatmentsforgallstones,usedaloneorincombination,includethe
following:
Oralbilesalttherapy(ursodeoxycholicacid)
Contactdissolution
Extracorporealshockwavelithotripsy
Medicalmanagementismoreeffectiveinpatientswithgoodgallbladderfunction
whohavesmallstones(<1cm)withahighcholesterolcontent.Bilesalttherapy
mayberequiredformorethan6monthsandhasasuccessratelessthan50%.

TreatmentofAsymptomaticGallstones
Surgicaltreatmentofasymptomaticgallstoneswithoutmedicallycomplicating
diseasesisdiscouraged.Theriskofcomplicationsarisingfrominterventionsis
higherthantheriskofsymptomaticdisease.Approximately25%ofpatientswith
asymptomaticgallstonesdevelopsymptomswithin10years.
Personswithdiabetesandwomenwhoarepregnantshouldhaveclosefollowupto
determineiftheybecomesymptomaticordevelopcomplications.
However,cholecystectomyforasymptomaticgallstonesmaybeindicatedinthe
followingpatients:
Patientswithlargegallstonesgreaterthan2cmindiameter
Patientswithnonfunctionalorcalcified(porcelain)gallbladderobservedon
imagingstudiesandwhoareathighriskofgallbladdercarcinoma
Patientswithspinalcordinjuriesorsensoryneuropathiesaffectingthe
abdomen
Patientswithsicklecellanemiainwhomthedistinctionbetweenpainful
crisisandcholecystitismaybedifficult
Patientswithriskfactorsforcomplicationsofgallstonesmaybeofferedelective
cholecystectomy,eveniftheyhaveasymptomaticgallstones.Thesegroupsinclude
personswiththefollowingconditionsanddemographics:
Cirrhosis
Portalhypertension
Children
Transplantcandidates
Diabeteswithminorsymptoms
Patientswithacalcifiedorporcelaingallbladdershouldconsiderelective
cholecystectomyduetothepossiblyincreasedriskofcarcinoma(25%).Refertoa
surgeonforremovalasanoutpatientprocedure.

Medicaldissolutionofgallstones
Ursodeoxycholicacid(ursodiol)isagallstonedissolutionagent.Inhumans,long
termadministrationofursodeoxycholicacidreducescholesterolsaturationofbile,
bothbyreducinglivercholesterolsecretionandbyreducingthedetergenteffectof
bilesaltsinthegallbladder(therebypreservingvesiclesthathaveahighcholesterol
carryingcapacity).Desaturationofbilepreventscrystalsfromformingand,infact,
mayallowgradualextractionofcholesterolfromexistingstones.
Inpatientswithestablishedcholesterolgallstones,treatmentwithursodeoxycholic
acidatadoseof810mg/kg/dPOdividedbid/tidmayresultingradualgallstone
dissolution.Thisinterventiontypicallyrequires618monthsandissuccessfulonly
withsmall,purelycholesterolstones.Patientsremainatriskforgallstone
complicationsuntildissolutioniscompleted.Therecurrencerateis50%within5
years.Moreover,afterdiscontinuationoftreatment,mostpatientsformnew
gallstonesoverthesubsequent510years.

TreatmentofPatientwithSymptomaticGallstones
Inpatientswithsymptomaticgallstones,discusstheoptionsforsurgicaland
nonsurgicalinterventionemergencyphysiciansshouldreferpatientstotheirprimary
careproviderandsurgicalconsultantforoutpatientfollowup.

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Cholecystectomy
Removalofthegallbladder(cholecystectomy)isgenerallyindicatedinpatientswho
haveexperiencedsymptomsorcomplicationsofgallstones,unlessthepatient'sage
andgeneralhealthmaketheriskofsurgeryprohibitive.Insomecasesof
gallbladderempyema,temporarydrainageofpusfromthegallbladder
(cholecystostomy)maybepreferredtoallowstabilizationandtopermitlater
cholecystectomyunderelectivecircumstances.
Inpatientswithgallbladderstoneswhoaresuspectedtohaveconcurrentcommon
bileductstones,thesurgeoncanperformintraoperativecholangiographyatthe
timeofcholecystectomy.Thecommonbileductcanbeexploredusinga
choledochoscope.Ifcommonductstonesarefound,theycanusuallybeextracted
intraoperatively.Alternatively,thesurgeoncancreateafistulabetweenthedistal
bileductandtheadjacentduodenum(choledochoduodenostomy),allowingstones
topassharmlesslyintotheintestine.

Openversuslaparoscopiccholecystectomy
Thefirstcholecystectomywasperformedinthelate1800s.Theopenapproach
pioneeredbyLangenbuchremainedthestandarduntilthelate1980s,when
laparoscopiccholecystectomywasintroduced. [16,17]Laparoscopiccholecystectomy
wasthevanguardoftheminimallyinvasiverevolution,whichhasaffectedallareas
ofmodernsurgicalpractice.Currently,opencholecystectomyismainlyreservedfor
specialsituations.
Thetraditionalopenapproachtocholecystectomyemployedalarge,rightsubcostal
incision.Incontrast,laparoscopiccholecystectomyemploys4verysmallincisions.
Recoverytimeandpostoperativepainarediminishedmarkedlybythelaparoscopic
approach.
Currently,laparoscopiccholecystectomyiscommonlyperformedinanoutpatient
setting.Byreducinginpatientstayandtimelostfromwork,thelaparoscopic
approachhasalsoreducedthecostofcholecystectomy. [18]
Inits2010guidelinesfortheclinicalapplicationoflaparoscopicbiliarytractsurgery,
theSocietyofAmericanGastrointestinalandEndoscopicSurgeons(SAGES)states
thatpatientswithsymptomaticcholelithiasisareeligibleforlaparoscopicsurgery.
Cholelithiasispatientswhoselaparoscopiccholecystectomywasuncomplicatedmay
besenthomethesamedayifpostoperativepainandnauseaarewellcontrolled.
Patientsolderthan50yearsmaybeatgreaterriskofreadmission. [19]
Duringlaparoscopiccholecystectomy,asurgeonmustretrievestonesthatmight
escapethroughaperforatedgallbladder.Conversiontoanopenproceduremightbe
requiredincertaincases.
Inpatientsinwhomgallstoneshavebeenlostintheperitonealcavity,thecurrent
recommendationisfollowupwithultrasonographicexaminationsfor12months.
Mostofthecomplications(usually,abscessformationaroundthestone)occur
withinthistimeframe.
Themostdreadedandmorbidcomplicationofcholecystectomyisdamagetothe
commonbileduct.Bileductinjuriesincreasedinincidencewiththeadventof
laparoscopiccholecystectomy,buttheincidenceofthiscomplicationhassince
declinedasexperienceandtraininginminimallyinvasivesurgeryhaveimproved. [20]
Routinecholangiographyisonlyofminimalhelpinpreventingcommonbileduct
injury.However,goodevidenceindicatesthatitleadstointraoperativedetectionof
suchinjuries.

Cholecystostomy
Inpatientswhoarecriticallyillwithgallbladderempyemaandsepsis,
cholecystectomycanbetreacherous.Inthiscircumstance,thesurgeonmayelectto
performcholecystostomy,aminimalprocedureinvolvingplacementofadrainage
tubeinthegallbladder.Thisusuallyresultsinclinicalimprovement.Oncethe
patientstabilizes,definitivecholecystectomycanbeperformedunderelective
circumstances.
Cholecystostomyalsocanbeperformedinsomecasesbyinvasiveradiologists
underCTscanguidance.Thisapproacheliminatestheneedforanesthesiaandis
especiallyappealinginapatientwhoisclinicallyunstable.

Endoscopicsphincterotomy
Ifsurgicalremovalofcommonbileductstonesisnotimmediatelyfeasible,
endoscopicretrogradesphincterotomycanbeused.Inthisprocedure,the
endoscopistcannulatesthebileductviathepapillaofVater.Usingan
electrocauterysphincterotome,theendoscopistmakesanincisionmeasuring
approximately1cmthroughthesphincterofOddiandtheintraduodenalportionof
thecommonbileduct,creatinganopeningthroughwhichstonescanbeextracted.
Endoscopicretrogradesphincterotomyisespeciallyusefulinpatientswhoare
criticallyillwithascendingcholangitiscausedbyimpactionofagallstoneinthe
ampullaofVater.Otherindicationsfortheprocedureareasfollows:
Removalofcommonbileductstonesinadvertentlyleftbehindduring
previouscholecystectomy
Preoperativeclearingofstonesfromthecommonbileducttoeliminatethe
needforintraoperativecommonbileductexploration,especiallyinsituations
wherethesurgeon'sexpertiseinlaparoscopicbileductexplorationislimited
orthepatient'sanesthesiariskishigh
Preventingrecurrenceofacutegallstonepancreatitisorothercomplications
ofcholedocholithiasisinpatientswhoaretoosickatpresenttoundergo
electivecholecystectomyorwhoselongtermprognosisispoor

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Intraoperativeendoscopicsphincterotomy(IOES)duringlaparoscopic
cholecystectomyhasbeensuggestedasanalternativetreatmenttopreoperative
endoscopicsphincterotomy(POES)followedbylaparoscopiccholecystectomythis
isbecauseIOESisaseffectiveandsafeasPOESandresultsinasignificantly
shorterhospitalstay. [21]

PreventionofGallstones
Ursodeoxycholicacidtreatmentcanpreventgallstoneformation.Thishasbeen
demonstratedinthesettingofrapidweightlosscausedbyverylowcaloriedietsor
bybariatricsurgery,whichareassociatedwithahighriskofnewcholesterol
gallstones(2030%within4mo).Administrationofursodeoxycholicacidatadose
of600mgdailyfor16weeksreducestheincidenceofgallstonesby80%inthis
setting.
Recommendingdietarychangesofdecreasedfatintakeisprudentthismay
decreasetheincidenceofbiliarycolicattacks.However,ithasnotbeenshownto
causedissolutionofstones.

DietandActivity
Littleevidencesuggeststhatdietarycompositionaffectsthenaturalhistoryof
gallstonediseaseinhumans.Obesepatientswhoundertakeaggressiveweightloss
programsorundergobariatricsurgeryareatrisktodevelopgallstonesshortterm
prophylaxiswithursodeoxycholicacidshouldbeconsidered.
Regularexercisemayreducethefrequencyofcholecystectomy.

Consultations
Patientswhohaveexperiencedanepisodeoftypicalbiliarycolicoracomplication
ofgallstonesshouldbereferredtoageneralsurgeonwithexperiencein
laparoscopiccholecystectomy.
Ifsymptomsareatypical,consultationwithageneralgastroenterologistmaybe
appropriate.Agastroenterologistspecializinginbiliaryendoscopyshouldbe
consultedifendoscopicretrogradesphincterotomymayberequired.

LongTermMonitoring
Followingcholecystectomy,about510%ofpatientsdevelopchronicdiarrhea.This
isusuallyattributedtobilesalts.Thefrequencyofenterohepaticcirculationofbile
saltsincreasesafterthegallbladderisremoved,resultinginmorebilesaltreaching
thecolon.Inthecolon,bilesaltsstimulatemucosalsecretionofsaltandwater.
Postcholecystectomydiarrheaisusuallymildandcanbemanagedwithoccasional
useofoverthecounterantidiarrhealagents,suchasloperamide.Morefrequent
diarrheacanbetreatedwithdailyadministrationofabileacidbindingresin(eg,
colestipol,cholestyramine,colesevelam).
Followingcholecystectomy,afewindividualsexperiencerecurrentpainresembling
biliarycolic.Thetermpostcholecystectomysyndromeissometimesusedforthis
condition.
Manypatientswithpostcholecystectomysyndromehavelongtermfunctionalpain
thatwasoriginallymisdiagnosedasbeingofbiliaryorigin. [22]Persistenceof
symptomsfollowingcholecystectomyisunsurprising.Diagnosticandtherapeutic
effortsshouldbedirectedatthetruecause.
Someindividualswithpostcholecystectomysyndromehaveanunderlyingmotility
disorderofthesphincterofOddi,termedbiliarydyskinesia,inwhichthesphincter
failstorelaxnormallyfollowingingestionofameal.Thediagnosiscanbe
establishedinspecializedcentersbyendoscopicbiliarymanometry.Inestablished
casesofbiliarydyskinesia,endoscopicretrogradesphincterotomyisusuallyeffective
inrelievingthesymptoms.
Medication

ContributorInformationandDisclosures
Author
DouglasMHeuman,MD,FACP,FACG,AGAFChiefofHepatology,HunterHolmesMcGuireDepartmentof
VeteransAffairsMedicalCenterProfessor,DepartmentofInternalMedicine,DivisionofGastroenterology,
VirginiaCommonwealthUniversitySchoolofMedicine
DouglasMHeuman,MD,FACP,FACG,AGAFisamemberofthefollowingmedicalsocieties:American
AssociationfortheStudyofLiverDiseases,AmericanCollegeofPhysicians,AmericanGastroenterological
Association
Disclosure:Receivedgrant/researchfundsfromNovartisforotherReceivedgrant/researchfundsfromBayerfor
otherReceivedgrant/researchfundsfromOtsukafornoneReceivedgrant/researchfundsfromBristolMyers
SquibbforotherReceivednonefromScynexisfornoneReceivedgrant/researchfundsfromSalixforother
Receivedgrant/researchfundsfromMannKindforother.
Coauthor(s)
JeffAllen,MDAssistantProfessor,DepartmentofSurgery,UniversityofLouisville
Disclosure:Nothingtodisclose.
AnastasiosAMihas,MD,DMSc,FACP,FACGProfessor,DepartmentofMedicine,Divisionof
Gastroenterology,VirginiaCommonwealthUniversitySchoolofMedicineConsultingStaff,Virginia
CommonwealthUniversityHospitalsandClinicsChiefofGIClinicalResearch,DirectorofGIOutpatientService,
AssociateDirectorofHepatology,HunterHolmesMcGuireVeteransAffairsMedicalCenter

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AnastasiosAMihas,MD,DMSc,FACP,FACGisamemberofthefollowingmedicalsocieties:American
AssociationfortheStudyofLiverDiseases,AmericanCollegeofGastroenterology,AmericanCollegeof
Physicians,AmericanGastroenterologicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,Sigma
Xi,SouthernSocietyforClinicalInvestigation,AmericanFederationforClinicalResearch,Gastroenterology
ResearchGroup
Disclosure:Nothingtodisclose.
ChiefEditor
JulianKatz,MDClinicalProfessorofMedicine,DrexelUniversityCollegeofMedicine
JulianKatz,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterology,
AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanGeriatricsSociety,
AmericanMedicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,AmericanSocietyofLaw,
Medicine&Ethics,AmericanTraumaSociety,AssociationofAmericanMedicalColleges,PhysiciansforSocial
Responsibility
Disclosure:Nothingtodisclose.
Acknowledgements
FirassAbiad,MDHeadofDivision,GeneralandLaparoscopicSurgery,SpecializedMedicalCenterHospital,
SaudiArabia
Disclosure:Nothingtodisclose.
BSAnand,MDProfessor,DepartmentofInternalMedicine,DivisionofGastroenterology,BaylorCollegeof
Medicine
BSAnand,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyofLiver
Diseases,AmericanCollegeofGastroenterology,AmericanGastroenterologicalAssociation,andAmerican
SocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
DavidEricBernstein,MDDirectorofHepatology,NorthShoreUniversityHospitalProfessorofClinical
Medicine,AlbertEinsteinCollegeofMedicine
DavidEricBernstein,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyof
LiverDiseases,AmericanCollegeofGastroenterology,AmericanCollegeofPhysicians,American
GastroenterologicalAssociation,andAmericanSocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,
ProgramDirector,EmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWesternReserve
UniversitySchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanAcademyofEmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeof
EmergencyPhysicians,AmericanCollegeofPhysicians,AmericanHeartAssociation,AmericanThoracic
Society,ArkansasMedicalSociety,NewYorkAcademyofMedicine,NewYorkAcademyofSciences,and
SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
DavidFMBrown,MDAssociateProfessor,DivisionofEmergencyMedicine,HarvardMedicalSchoolVice
Chair,DepartmentofEmergencyMedicine,MassachusettsGeneralHospital
DavidFMBrown,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
PhysiciansandSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
WilliamKChiang,MDAssociateProfessor,DepartmentofEmergencyMedicine,NewYorkUniversitySchool
ofMedicineChiefofService,DepartmentofEmergencyMedicine,BellevueHospitalCenter
WilliamKChiang,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofClinicalToxicology,
AmericanCollegeofMedicalToxicology,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
AlfredCuschieri,MD,ChM,FRSE,FRCS,Head,Professor,DepartmentofSurgeryandMolecularOncology,
UniversityofDundee,UK
Disclosure:Nothingtodisclose.
ImadSDandan,MDConsultingSurgeon,DepartmentofSurgery,TraumaSection,ScrippsMemorialHospital
ImadSDandan,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheSurgeryof
Trauma,AmericanCollegeofSurgeons,AmericanMedicalAssociation,AmericanTraumaSociety,California
MedicalAssociation,andSocietyofCriticalCareMedicine
Disclosure:Nothingtodisclose.
DavidGreenwald,MDAssociateProfessorofClinicalMedicine,FellowshipProgramDirector,Departmentof
Medicine,DivisionofGastroenterology,MontefioreMedicalCenter,AlbertEinsteinCollegeofMedicine
DavidGreenwald,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeof
Gastroenterology,AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanSociety
forGastrointestinalEndoscopy,andNewYorkSocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergency
Medicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,
MartinLutherKingJr/DrewMedicalCenter
Disclosure:Nothingtodisclose.
FayeMaryannLee,MDStaffPhysician,DepartmentofEmergencyMedicine,NewYorkUniversity/Bellevue

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HospitalCenter
FayeMaryannLee,MDisamemberofthefollowingmedicalsocieties:PhiBetaKappa
Disclosure:Nothingtodisclose.
SallySanten,MDProgramDirector,AssistantProfessor,DepartmentofEmergencyMedicine,Vanderbilt
University
SallySanten,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians
andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
AssaadMSoweid,MD,FASGE,FACGAssociateProfessorofClinicalMedicine,Endosonographyand
AdvancedTherapeuticEndoscopy,Director,EndoscopyBronchoscopyUnit,DivisionofGastroenterology,
DepartmentofInternalMedicine,AmericanUniversityofBeirutMedicalCenter,Lebanon
AssaadMSoweid,MD,FASGE,FACGisamemberofthefollowingmedicalsocieties:AmericanCollegeof
Gastroenterology,AmericanCollegeofPhysicians,AmericanCollegeofPhysiciansAmericanSocietyofInternal
Medicine,AmericanGynecologicalandObstetricalSociety,andAmericanMedicalAssociation
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

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