Treatment

• Asymptomatic cholelithiasis

  • Expectant management is typically sufficient.

  • Consider the need for prophylactic cholecystectomy: See “Indications” in “Surgical Management.”

• Symptomatic uncomplicated cholelithiasis

  • Treatment of biliary colic

    • Provide initial supportive therapy for acute biliary disease.

    • Counsel on lifestyle modifications to prevent further attacks (see “Nonoperative management of cholelithiasis” for details.)

  • Outpatient referral to general surgery for an elective cholecystectomy to prevent recurrence.

• Symptomatic complicated cholelithiasis

  • Admit for further management.

• Bowel rest: NPO

• Analgesics

  • NSAIDs: preferred first-line analgesics

    • Ketorolac

    • Diclofenac

    • Ibuprofen

  • Opioids: for severe pain that does not improve with NSAIDs or in patients with contraindications to NSAIDs

    • Morphine

    • Buprenorphine

    • Meperidine

    • See also “Pain management.”

• Spasmolytics (e.g., dicyclomine): consider as adjuvant therapy with analgesics in patients with severe pain

• Treatment for protracted vomiting

  • IV fluid therapy

  • Antiemetics

  • Consider NG tube insertion with suction.

• Procedure: elective laparoscopic cholecystectomy

• Indications

  • Symptomatic cholelithiasis

  • Asymptomatic cholelithiasis with any of the following:

    • Increased risk of gallbladder cancer (e.g., gallbladder polyps, porcelain gallbladder, gallstones ≥ 3 cm)

    • Increased risk of developing complications (e.g., immunocompromised patients, multiple gallstones)

    • Increased risk of becoming symptomatic (e.g., hemolytic anemia, patients undergoing gastric bypass surgery)

• Contraindication: suspected gallbladder cancer

• Preoperative precautions: Assess for predictors of choledocholithiasis in all symptomatic patients

• Timing: as early as possible in uncomplicated symptomatic cholelithiasis

• Cholecystectomy is usually not indicated in asymptomatic cholelithiasis.

Indications

• Patients at high risk of complications due to surgery or anesthesia (e.g., recent myocardial infarction)

• Patients unwilling to undergo surgery

Expectant management

• Lifestyle modifications :

  • Low-fat diet (especially low in saturated fats)

  • Avoid lithogenic drugs, such as estrogen, fibrates.

  • Exercise regularly.

• Follow-up: if symptoms recur

• May be useful in dissolving pure cholesterol stones (i.e., radiolucent stones) that are < 0.5 cm [17]

• Ursodeoxycholic acid

• Duration of therapy: 6–24 months

ESWL is also used in the treatment of nephrolithiasis.

• Definition: a noninvasive method of stone fragmentation using an acoustic pulse in the treatment of gallstones and pancreatic stones

• Indication: typically used for solitary stones that can be localized well on imaging (radiolucent)

• Procedure

  • Stones are localized using x-ray or ultrasound.

  • A lithotriptor generates shock waves that are focused on the stone, fragmenting it in the process.

  • Passage of stone fragments

    • Biliary stones: through the biliary system into the duodenum.

    • Pancreatic stones: through the pancreatic duct into the duodenum

• Advantage: is noninvasive and can be performed on an outpatient basis

• Disadvantages

  • Commonly causes biliary colic

  • Lower success rate in the presence of multiple stones

  • Risk of injury to adjacent solid organs (rare)

• Prognosis: high recurrence rate (between 40 and 60% within 5 years)