eMedicine Specialties > Emergency Medicine > Gastrointestinal

Cholelithiasis: Treatment & Medication

Author: William K Chiang, MD, Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center
Coauthor(s): Faye Maryann Lee, MD, Staff Physician, Department of Emergency Medicine, New York University/Bellevue Hospital Center; Sally Santen, MD, Program Director, Assistant Professor, Department of Emergency Medicine, Vanderbilt University
Contributor Information and Disclosures

Updated: Nov 3, 2009

Treatment

Emergency Department Care

Gallstones found incidentally may be followed until they become symptomatic.

  • 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.
  • In patients with symptomatic gallstones, discuss the options for surgical and nonsurgical intervention and refer the patient to their primary care provider and surgical consultant for outpatient follow-up.
  • Persons with diabetes and women who are pregnant should have close follow-up to determine if they become symptomatic or develop complications.
  • Patients with risk factors for complications of gallstones may be offered elective cholecystectomy, even with asymptomatic gallstones. These groups include persons with the following conditions and demographics:
    • Cirrhosis
    • Portal hypertension
    • Sickle cell disease
    • Children
    • Transplant candidates
    • Diabetes with minor symptoms
  • Patients with a calcified or porcelain gallbladder should consider elective cholecystectomy due to the increased risk of carcinoma (25%). Refer to a surgeon for removal as an outpatient procedure.
  • If cholecystitis or other infectious complication is suspected, emergent consultation with a general surgeon should be obtained.
  • See related eMedicine articles, Cholecystectomy, Laparoscopic; Cholecystectomy, Open; and Cholecystectomy, Single Port.

Consultations

  • In patients with symptomatic gallstones, discuss the options of medical management or elective surgery with the patient and refer for follow-up to the primary care provider and general surgeon. Use of a single-step procedure of laparoscopic cholecystectomy (LC) and intraoperative endoscopic retrograde cholangiopancreatography (LC+IO-ERCP) and endoscopic sphincterotomy (ES) has shown promising results on patients with gallbladder stones and with confirmed or suspected common bile duct stones.4
  • Refer patients with a calcified or porcelain gallbladder to a surgeon for removal on an outpatient basis.
  • Emergency consultation with a general surgeon should be sought if cholecystitis is strongly suspected or diagnosed.

Medication

For asymptomatic gallstones, medical therapies are rarely used because they require long-term therapy, may have adverse reactions or complications, and recurrence of gallstones is relatively common (25% within 5 years).

In patients who present with an acute attack of biliary colic, pain can be controlled with oral or parenteral opioids.

Elective cholecystectomy is the treatment of choice for symptomatic cholelithiasis.5,6 In uncomplicated cholelithiasis with biliary colic, medical management may be a useful alternative to cholecystectomy in selected patients, particularly in patients with high surgical risk. Medical treatment, beyond pain control, however, is not initiated in the emergency department, and patients should be referred to their primary care provider for further medical management.

Medical management of gallstones, used alone or in combination, include the following: oral bile salt therapy (ursodeoxycholic acid, chenodeoxycholic acid), contact dissolution, and extracorporeal shockwave lithotripsy. Medical management is more efficacious in patients with small stones (<1 cm), high cholesterol content, and good gallbladder function.

More on Cholelithiasis

Overview: Cholelithiasis
Differential Diagnoses & Workup: Cholelithiasis
Treatment & Medication: Cholelithiasis
Follow-up: Cholelithiasis
Multimedia: Cholelithiasis
References
Further Reading
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References

  1. Sun H, Tang H, Jiang S, Zeng L, Chen EQ, Zhou TY, et al. Gender and metabolic differences of gallstone diseases. World J Gastroenterol. Apr 21 2009;15(15):1886-91. [Medline].

  2. Gilani SN, Bass G, Leader F, Walsh TN. Collins' sign: validation of a clinical sign in cholelithiasis. Ir J Med Sci. Aug 14 2009;[Medline].

  3. Dauer M, Lammert F. Mandatory and optional function tests for biliary disorders. Best Pract Res Clin Gastroenterol. 2009;23(3):441-51. [Medline].

  4. Ghazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of gall bladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg. May 26 2009;[Medline].

  5. Dan DV, Harnanan D, Maharaj R, Seetahal S, Singh Y, Naraynsingh V. Laparoscopic cholecystectomy: analysis of 619 consecutive cases in a Caribbean setting. J Natl Med Assoc. Apr 2009;101(4):355-60. [Medline].

  6. Boddy A. Timing of surgery for symptomatic gallstones. Ann R Coll Surg Engl. May 2009;91(4):354-5. [Medline].

  7. Besselink MG, Venneman NG, Go PM, Broeders IA, Siersema PD, Gooszen HG, et al. Is complicated gallstone disease preceded by biliary colic?. J Gastrointest Surg. Feb 2009;13(2):312-7. [Medline].

  8. Zaliekas J, Munson JL. Complications of gallstones: the Mirizzi syndrome, gallstone ileus, gallstone pancreatitis, complications of "lost" gallstones. Surg Clin North Am. Dec 2008;88(6):1345-68, x. [Medline].

  9. Bennett GL, Balthazar EJ. Ultrasound and CT evaluation of emergent gallbladder pathology. Radiol Clin North Am. Nov 2003;41(6):1203-16. [Medline].

  10. Cohen SA, Siegel JH. Biliary tract emergencies. Endoscopic and medical management. Crit Care Clin. Apr 1995;11(2):273-94. [Medline].

  11. Giurgiu DI, Roslyn JJ. Treatment of gallstones in the 1990s. Prim Care. Sep 1996;23(3):497-513. [Medline].

  12. Glambek I, Arnesjo B, Soreide O. Correlation between gallstones and abdominal symptoms in a random population. Results from a screening study. Scand J Gastroenterol. Apr 1989;24(3):277-81. [Medline].

  13. Janowitz P, Kratzer W, Zemmler T, et al. Gallbladder sludge: spontaneous course and incidence of complications in patients without stones. Hepatology. Aug 1994;20(2):291-4. [Medline].

  14. Moscati RM. Cholelithiasis, cholecystitis, and pancreatitis. Emerg Med Clin North Am. Nov 1996;14(4):719-37. [Medline].

  15. Sievert W, Vakil NB. Emergencies of the biliary tract. Gastroenterol Clin North Am. Jun 1988;17(2):245-64. [Medline].

  16. Swisher SG, Schmit PJ, Hunt KK, et al. Biliary disease during pregnancy. Am J Surg. Dec 1994;168(6):576-9; discussion 580-1. [Medline].

  17. Tait N, Little JM. The treatment of gall stones. BMJ. Jul 8 1995;311(6997):99-105. [Medline].

  18. Talley NJ. Gallstones and upper abdominal discomfort. Innocent bystander or a cause of dyspepsia?. J Clin Gastroenterol. Apr 1995;20(3):182-3. [Medline].

  19. Tsimoyiannis E, Antoniou NC, Tsaboulas T, Papanikolaou N. Cholelithiasis during pregnancy and lactation. Eur J Surg. 1994;160:627-631. [Medline].

  20. Weltman DI, Zeman RK. Acute diseases of the gallbladder and biliary ducts. Radiol Clin North Am. Sep 1994;32(5):933-50. [Medline].

  21. Yusoff IF, Barkun JS, Barkun AN. Diagnosis and management of cholecystitis and cholangitis. Gastroenterol Clin North Am. Dec 2003;32(4):1145-68. [Medline].

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Further Reading

Clinical guidelines
ACR Appropriateness Criteria® right upper quadrant pain.
American College of Radiology - Medical Specialty Society. 1996 (revised 2005). 5 pages. [NGC Update Pending] NGC:004781

ASGE technology status evaluation report: radiographic contrast media used in ERCP.
American Society for Gastrointestinal Endoscopy - Medical Specialty Society. 2005 Oct. 5 pages. NGC:004546

Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy.
Society of American Gastrointestinal and Endoscopic Surgeons - Medical Specialty Society. 1996 Feb (revised 2007 Sep). 25 pages. NGC:005977


Clinical trials

Laparoendoscopic Rendez Vous Versus Standard Two Stage Approach for the Management of Cholelithiasis/Choledocholithiasis

Minimally Invasive Surgery: Using Natural Orfices (NOTES)

Comparison of Single Trocar Cholecystectomy to Standard Laparoscopic Cholecystectomy

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Keywords

gallstones, gallstones symptoms, gallstones treatment, gallstones diet, gallbladder colic, cholesterol stones, gallbladder disease, cholecystitis, choledocholithiasis, cholangitis, cholesterol gallstones, biliary colic, cirrhosis

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Contributor Information and Disclosures

Author

William K Chiang, MD, Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center
William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Faye Maryann Lee, MD, Staff Physician, Department of Emergency Medicine, New York University/Bellevue Hospital Center
Faye Maryann Lee, MD is a member of the following medical societies: Phi Beta Kappa
Disclosure: Nothing to disclose.

Sally Santen, MD, Program Director, Assistant Professor, Department of Emergency Medicine, Vanderbilt University
Sally Santen, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

David FM Brown, MD, Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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