eMedicine Specialties > Gastroenterology > Biliary

Cholelithiasis: Treatment & Medication

Author: Douglas M Heuman, MD, FACP, FACG, AGAF, Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine
Coauthor(s): Anastasios A Mihas, MD, DMSc, FACP, FACG, Professor, Department of Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine; Consulting Staff, Virginia Commonwealth University Hospitals and Clinics; Chief of GI Clinical Research, Director of GI Outpatient Service, Associate Director of Hepatology, Hunter Holmes McGuire Veterans Affairs Medical Center; Jeff Allen, MD, Assistant Professor, Department of Surgery, University of Louisville
Contributor Information and Disclosures

Updated: Aug 25, 2009

Treatment

Medical Care

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. Additional interventions may be of value to address acute complications of gallstones, especially in patients who are too sick to tolerate cholecystectomy, and to clear stones from the common bile duct.

• Ursodeoxycholic acid (ursodiol)
  • Ursodeoxycholic acid is a natural bile salt of bears. It is a weak detergent.
  • 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.
  • Ursodeoxycholic acid can be used in 2 ways, as follows:
    • 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.
    • In patients with established cholesterol gallstones, treatment with ursodeoxycholic acid at a dose of 12-15 mg/kg daily 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. Dissolution fails in many cases. Moreover, after discontinuation of treatment, most patients will form new gallstones over the subsequent 5-10 years.

Surgical Care

Removal of the gallbladder (cholecystectomy) is the treatment of choice for symptomatic cholelithiasis. 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. At the time of cholecystectomy, the surgeon can explore the common bile duct and remove common bile duct stones. 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.

If surgical removal of common bile duct stones is not immediately feasible, endoscopy can be used to extract common bile duct stones via a small incision in the papilla of Vater (endoscopic sphincterotomy). This approach is especially useful in patients who are critically ill with ascending cholangitis, but it may also be used to remove common bile duct stones inadvertently left behind during previous cholecystectomy.

• Cholecystectomy: The first cholecystectomy was performed in the late 1800s. The open approach via subcostal incision pioneered by Langenbuch remained the standard until the late 1980s, when laparoscopic cholecystectomy was introduced.^5,6 Laparoscopic cholecystectomy was the vanguard of the minimally invasive revolution, which has affected all areas of modern surgical practice. Currently, open cholecystomy 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, the procedure 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.
  • 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 improve. 
  • 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.
  • Because the natural history of gallstones is generally benign, cholecystectomy is not required for patients with asymptomatic gallstones. However, cholecystectomy for asymptomatic gallstones may be indicated under certain circumstances. These circumstances may include:
    • 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
• 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 circumstance.
• 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.
• 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.
• Endoscopic retrograde sphincterotomy is a medical procedure used to remove gallstones from the common bile duct. The endoscopist cannulates the bile duct via the papilla of Vater. Using an electrocautery sphincterotome, an incision measuring approximately 1 cm is made 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 useful in several circumstances, as follows:
  • Achieving biliary drainage in the patient with ascending cholangitis caused by impaction of a gallstone in the ampulla of Vater
  • 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

Consultations

Patients with asymptomatic gallstones can be managed expectantly.

• 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.

Diet

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.

Activity

Regular exercise may reduce the frequency of cholecystectomy.

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