Cholelithiasis Treatment & Management

The treatment of gallstones depends upon the stage of disease. Ideally, interventions in the lithogenic state could prevent gallstone formation, although, currently, this option is limited to a few special circumstances. Asymptomatic gallstones may be managed expectantly.

Once gallstones become symptomatic, definitive surgical intervention with cholecystectomy is usually indicated, although, in some cases, medical dissolution may be considered. In uncomplicated cholelithiasis with biliary colic, medical management may be a useful alternative to cholecystectomy in selected patients, particularly those for whom surgery would pose high risk. Medical treatment, beyond pain control, is not initiated in the emergency department.

Medical treatments for gallstones, used alone or in combination, include the following:

• Oral bile salt therapy (ursodeoxycholic acid)
• Contact dissolution
• Extracorporeal shockwave lithotripsy

Medical management is more effective in patients with good gallbladder function who have small stones (< 1 cm) with a high cholesterol content. Bile salt therapy may be required for more than 6 months and has a success rate less than 50%.

Surgical treatment of asymptomatic gallstones without medically complicating diseases is discouraged. The risk of complications arising from interventions is higher than the risk of symptomatic disease. Approximately 25% of patients with asymptomatic gallstones develop symptoms within 10 years.

Persons with diabetes and women who are pregnant should have close follow-up to determine if they become symptomatic or develop complications.

However, cholecystectomy for asymptomatic gallstones may be indicated in the following patients:

• Patients with large gallstones greater than 2 cm in diameter
• Patients with nonfunctional or calcified (porcelain) gallbladder observed on imaging studies and who are at high risk of gallbladder carcinoma
• Patients with spinal cord injuries or sensory neuropathies affecting the abdomen
• Patients with sickle cell anemia in whom the distinction between painful crisis and cholecystitis may be difficult

Patients with risk factors for complications of gallstones may be offered elective cholecystectomy, even if they have asymptomatic gallstones. These groups include persons with the following conditions and demographics:

• Cirrhosis
• Portal hypertension
• Children
• Transplant candidates
• Diabetes with minor symptoms

Patients with a calcified or porcelain gallbladder should consider elective cholecystectomy due to the possibly increased risk of carcinoma (25%). Refer to a surgeon for removal as an outpatient procedure.

Medical dissolution of gallstones

Ursodeoxycholic acid (ursodiol) is a gallstone dissolution agent. In humans, long-term administration of ursodeoxycholic acid reduces cholesterol saturation of bile, both by reducing liver cholesterol secretion and by reducing the detergent effect of bile salts in the gallbladder (thereby preserving vesicles that have a high cholesterol carrying capacity). Desaturation of bile prevents crystals from forming and, in fact, may allow gradual extraction of cholesterol from existing stones.

In patients with established cholesterol gallstones, treatment with ursodeoxycholic acid at a dose of 8-10 mg/kg/d PO divided bid/tid may result in gradual gallstone dissolution. This intervention typically requires 6-18 months and is successful only with small, purely cholesterol stones. Patients remain at risk for gallstone complications until dissolution is completed. The recurrence rate is 50% within 5 years. Moreover, after discontinuation of treatment, most patients form new gallstones over the subsequent 5-10 years.

In patients with symptomatic gallstones, discuss the options for surgical and nonsurgical intervention; emergency physicians should refer patients to their primary care provider and surgical consultant for outpatient follow-up.

Cholecystectomy

Removal of the gallbladder (cholecystectomy) is generally indicated in patients who have experienced symptoms or complications of gallstones, unless the patient's age and general health make the risk of surgery prohibitive. In some cases of gallbladder empyema, temporary drainage of pus from the gallbladder (cholecystostomy) may be preferred to allow stabilization and to permit later cholecystectomy under elective circumstances.

In patients with gallbladder stones who are suspected to have concurrent common bile duct stones, the surgeon can perform intraoperative cholangiography at the time of cholecystectomy. The common bile duct can be explored using a choledochoscope. If common duct stones are found, they can usually be extracted intraoperatively. Alternatively, the surgeon can create a fistula between the distal bile duct and the adjacent duodenum (choledochoduodenostomy), allowing stones to pass harmlessly into the intestine.

Open versus laparoscopic cholecystectomy

The first cholecystectomy was performed in the late 1800s. The open approach pioneered by Langenbuch remained the standard until the late 1980s, when laparoscopic cholecystectomy was introduced.^{[14, 15]} Laparoscopic cholecystectomy was the vanguard of the minimally invasive revolution, which has affected all areas of modern surgical practice. Currently, open cholecystectomy is mainly reserved for special situations.

The traditional open approach to cholecystectomy employed a large, right subcostal incision. In contrast, laparoscopic cholecystectomy employs 4 very small incisions. Recovery time and postoperative pain are diminished markedly by the laparoscopic approach.

Currently, laparoscopic cholecystectomy is commonly performed in an outpatient setting. By reducing inpatient stay and time lost from work, the laparoscopic approach has also reduced the cost of cholecystectomy.

In its 2010 guidelines for the clinical application of laparoscopic biliary tract surgery, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) states that patients with symptomatic cholelithiasis are eligible for laparoscopic surgery. Cholelithiasis patients whose laparoscopic cholecystectomy was uncomplicated may be sent home the same day if postoperative pain and nausea are well controlled. Patients older than 50 years may be at greater risk of readmission.^[16]

During laparoscopic cholecystectomy, a surgeon must retrieve stones that might escape through a perforated gallbladder. Conversion to an open procedure might be required in certain cases.

In patients in whom gallstones have been lost in the peritoneal cavity, the current recommendation is follow-up with ultrasonographic examinations for 12 months. Most of the complications (usually, abscess formation around the stone) occur within this time frame.

The most dreaded and morbid complication of cholecystectomy is damage to the common bile duct. Bile duct injuries increased in incidence with the advent of laparoscopic cholecystectomy, but the incidence of this complication has since declined as experience and training in minimally invasive surgery have improved.^[17]

Routine cholangiography is only of minimal help in preventing common bile duct injury. However, good evidence indicates that it leads to intraoperative detection of such injuries.

Cholecystostomy

In patients who are critically ill with gallbladder empyema and sepsis, cholecystectomy can be treacherous. In this circumstance, the surgeon may elect to perform cholecystostomy, a minimal procedure involving placement of a drainage tube in the gallbladder. This usually results in clinical improvement. Once the patient stabilizes, definitive cholecystectomy can be performed under elective circumstances.

Cholecystostomy also can be performed in some cases by invasive radiologists under CT-scan guidance. This approach eliminates the need for anesthesia and is especially appealing in a patient who is clinically unstable.

Endoscopic sphincterotomy

If surgical removal of common bile duct stones is not immediately feasible, endoscopic retrograde sphincterotomy can be used. In this procedure, the endoscopist cannulates the bile duct via the papilla of Vater. Using an electrocautery sphincterotome, the endoscopist makes an incision measuring approximately 1 cm through the sphincter of Oddi and the intraduodenal portion of the common bile duct, creating an opening through which stones can be extracted.

Endoscopic retrograde sphincterotomy is especially useful in patients who are critically ill with ascending cholangitis caused by impaction of a gallstone in the ampulla of Vater. Other indications for the procedure are as follows:

• Removal of common bile duct stones inadvertently left behind during previous cholecystectomy
• Preoperative clearing of stones from the common bile duct to eliminate the need for intraoperative common bile duct exploration, especially in situations where the surgeon's expertise in laparoscopic bile duct exploration is limited or the patient's anesthesia risk is high
• Preventing recurrence of acute gallstone pancreatitis or other complications of choledocholithiasis in patients who are too sick at present to undergo elective cholecystectomy or whose long-term prognosis is poor

Intraoperative endoscopic sphincterotomy (IOES) during laparoscopic cholecystectomy has been suggested as an alternative treatment to preoperative endoscopic sphincterotomy (POES) followed by laparoscopic cholecystectomy; this is because IOES is as effective and safe as POES and results in a significantly shorter hospital stay.^[18]

Ursodeoxycholic acid treatment can prevent gallstone formation. This has been demonstrated in the setting of rapid weight loss caused by very low-calorie diets or by bariatric surgery, which are associated with a high risk of new cholesterol gallstones (20-30% within 4 mo). Administration of ursodeoxycholic acid at a dose of 600 mg daily for 16 weeks reduces the incidence of gallstones by 80% in this setting.

Recommending dietary changes of decreased fat intake is prudent; this may decrease the incidence of biliary colic attacks. However, it has not been shown to cause dissolution of stones.

Little evidence suggests that dietary composition affects the natural history of gallstone disease in humans. Obese patients who undertake aggressive weight-loss programs or undergo bariatric surgery are at risk to develop gallstones; short-term prophylaxis with ursodeoxycholic acid should be considered.

Regular exercise may reduce the frequency of cholecystectomy.

Patients who have experienced an episode of typical biliary colic or a complication of gallstones should be referred to a general surgeon with experience in laparoscopic cholecystectomy.

If symptoms are atypical, consultation with a general gastroenterologist may be appropriate. A gastroenterologist specializing in biliary endoscopy should be consulted if endoscopic retrograde sphincterotomy may be required.

Following cholecystectomy, about 5-10% of patients develop chronic diarrhea. This is usually attributed to bile salts. The frequency of enterohepatic circulation of bile salts increases after the gallbladder is removed, resulting in more bile salt reaching the colon. In the colon, bile salts stimulate mucosal secretion of salt and water.

Postcholecystectomy diarrhea is usually mild and can be managed with occasional use of over-the-counter antidiarrheal agents, such as loperamide. More frequent diarrhea can be treated with daily administration of a bile acid-binding resin (eg, colestipol, cholestyramine, colesevelam).

Following cholecystectomy, a few individuals experience recurrent pain resembling biliary colic. The term postcholecystectomy syndrome is sometimes used for this condition.

Many patients with postcholecystectomy syndrome have long-term functional pain that was originally misdiagnosed as being of biliary origin.^[19] Persistence of symptoms following cholecystectomy is unsurprising. Diagnostic and therapeutic efforts should be directed at the true cause.

Some individuals with postcholecystectomy syndrome have an underlying motility disorder of the sphincter of Oddi, termed biliary dyskinesia, in which the sphincter fails to relax normally following ingestion of a meal. The diagnosis can be established in specialized centers by endoscopic biliary manometry. In established cases of biliary dyskinesia, endoscopic retrograde sphincterotomy is usually effective in relieving the symptoms.