Gallstones (Cholelithiasis) Treatment & Management_ Approach Considerations, Treatment of Asymptomatic Gallstones, Treatment of Patient With Symptomatic Gallstones

10/13/2015 Gallstones (Cholelithiasis) Treatment & Management: Approach Considerations, Treatment of Asymptomatic Gallstones, Treatment of Patient wit…

http://emedicine.medscape.com/article/175667treatment 1/6

Gallstones (Cholelithiasis) Treatment & ManagementAuthor: Douglas M Heuman, MD, FACP, FACG, AGAF; Chief Editor: Julian Katz, MD more...

Updated: Jan 20, 2015

Approach ConsiderationsThe 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. Asymptomaticgallstones may be managed expectantly.

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

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

Oral bile salt therapy (ursodeoxycholic acid)Contact dissolutionExtracorporeal shockwave lithotripsy

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

Treatment of Asymptomatic GallstonesSurgical treatment of asymptomatic gallstones without medically complicatingdiseases is discouraged. The risk of complications arising from interventions ishigher than the risk of symptomatic disease. Approximately 25% of patients withasymptomatic gallstones develop symptoms within 10 years.

Persons with diabetes and women who are pregnant should have close followup todetermine if they become symptomatic or develop complications.

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

Patients with large gallstones greater than 2 cm in diameterPatients with nonfunctional or calcified (porcelain) gallbladder observed onimaging studies and who are at high risk of gallbladder carcinomaPatients with spinal cord injuries or sensory neuropathies affecting theabdomenPatients with sickle cell anemia in whom the distinction between painfulcrisis and cholecystitis may be difficult

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

CirrhosisPortal hypertensionChildrenTransplant candidatesDiabetes with minor symptoms

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

Medical dissolution of gallstones

Ursodeoxycholic acid (ursodiol) is a gallstone dissolution agent. In humans, longterm administration of ursodeoxycholic acid reduces cholesterol saturation of bile,both by reducing liver cholesterol secretion and by reducing the detergent effect ofbile salts in the gallbladder (thereby preserving vesicles that have a high cholesterolcarrying 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 ursodeoxycholicacid at a dose of 810 mg/kg/d PO divided bid/tid may result in gradual gallstonedissolution. This intervention typically requires 618 months and is successful onlywith small, purely cholesterol stones. Patients remain at risk for gallstonecomplications until dissolution is completed. The recurrence rate is 50% within 5years. Moreover, after discontinuation of treatment, most patients form newgallstones over the subsequent 510 years.

Treatment of Patient with Symptomatic GallstonesIn patients with symptomatic gallstones, discuss the options for surgical andnonsurgical intervention; emergency physicians should refer patients to their primarycare provider and surgical consultant for outpatient followup.



Cholecystectomy

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

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

Open versus laparoscopic cholecystectomy

The first cholecystectomy was performed in the late 1800s. The open approachpioneered by Langenbuch remained the standard until the late 1980s, whenlaparoscopic cholecystectomy was introduced.[16, 17] Laparoscopic cholecystectomywas the vanguard of the minimally invasive revolution, which has affected all areasof modern surgical practice. Currently, open cholecystectomy is mainly reserved forspecial situations.

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

Currently, laparoscopic cholecystectomy is commonly performed in an outpatientsetting. By reducing inpatient stay and time lost from work, the laparoscopicapproach has also reduced the cost of cholecystectomy.[18]

In its 2010 guidelines for the clinical application of laparoscopic biliary tract surgery,the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) statesthat patients with symptomatic cholelithiasis are eligible for laparoscopic surgery.Cholelithiasis patients whose laparoscopic cholecystectomy was uncomplicated maybe 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.[19]

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

In patients in whom gallstones have been lost in the peritoneal cavity, the currentrecommendation is followup with ultrasonographic examinations for 12 months.Most of the complications (usually, abscess formation around the stone) occurwithin this time frame.

The most dreaded and morbid complication of cholecystectomy is damage to thecommon bile duct. Bile duct injuries increased in incidence with the advent oflaparoscopic cholecystectomy, but the incidence of this complication has sincedeclined as experience and training in minimally invasive surgery have improved.[20]

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

Cholecystostomy

In patients who are critically ill with gallbladder empyema and sepsis,cholecystectomy can be treacherous. In this circumstance, the surgeon may elect toperform cholecystostomy, a minimal procedure involving placement of a drainagetube in the gallbladder. This usually results in clinical improvement. Once thepatient stabilizes, definitive cholecystectomy can be performed under electivecircumstances.

Cholecystostomy also can be performed in some cases by invasive radiologistsunder CTscan guidance. This approach eliminates the need for anesthesia and isespecially 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, theendoscopist cannulates the bile duct via the papilla of Vater. Using anelectrocautery sphincterotome, the endoscopist makes an incision measuringapproximately 1 cm through the sphincter of Oddi and the intraduodenal portion ofthe common bile duct, creating an opening through which stones can be extracted.

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

Removal of common bile duct stones inadvertently left behind duringprevious cholecystectomyPreoperative clearing of stones from the common bile duct to eliminate theneed for intraoperative common bile duct exploration, especially in situationswhere the surgeon's expertise in laparoscopic bile duct exploration is limitedor the patient's anesthesia risk is highPreventing recurrence of acute gallstone pancreatitis or other complicationsof choledocholithiasis in patients who are too sick at present to undergoelective cholecystectomy or whose longterm prognosis is poor

http://emedicine.medscape.com/article/434014-overview



Intraoperative endoscopic sphincterotomy (IOES) during laparoscopiccholecystectomy has been suggested as an alternative treatment to preoperativeendoscopic sphincterotomy (POES) followed by laparoscopic cholecystectomy; thisis because IOES is as effective and safe as POES and results in a significantlyshorter hospital stay.[21]

Prevention of GallstonesUrsodeoxycholic acid treatment can prevent gallstone formation. This has beendemonstrated in the setting of rapid weight loss caused by very lowcalorie diets orby bariatric surgery, which are associated with a high risk of new cholesterolgallstones (2030% within 4 mo). Administration of ursodeoxycholic acid at a doseof 600 mg daily for 16 weeks reduces the incidence of gallstones by 80% in thissetting.

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

Diet and ActivityLittle evidence suggests that dietary composition affects the natural history ofgallstone disease in humans. Obese patients who undertake aggressive weightlossprograms or undergo bariatric surgery are at risk to develop gallstones; shorttermprophylaxis with ursodeoxycholic acid should be considered.

Regular exercise may reduce the frequency of cholecystectomy.

ConsultationsPatients who have experienced an episode of typical biliary colic or a complicationof gallstones should be referred to a general surgeon with experience inlaparoscopic cholecystectomy.

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

LongTerm MonitoringFollowing cholecystectomy, about 510% of patients develop chronic diarrhea. Thisis usually attributed to bile salts. The frequency of enterohepatic circulation of bilesalts increases after the gallbladder is removed, resulting in more bile salt reachingthe colon. In the colon, bile salts stimulate mucosal secretion of salt and water.

Postcholecystectomy diarrhea is usually mild and can be managed with occasionaluse of overthecounter antidiarrheal agents, such as loperamide. More frequentdiarrhea can be treated with daily administration of a bile acidbinding resin (eg,colestipol, cholestyramine, colesevelam).

Following cholecystectomy, a few individuals experience recurrent pain resemblingbiliary colic. The term postcholecystectomy syndrome is sometimes used for thiscondition.

Many patients with postcholecystectomy syndrome have longterm functional painthat was originally misdiagnosed as being of biliary origin.[22] Persistence ofsymptoms following cholecystectomy is unsurprising. Diagnostic and therapeuticefforts should be directed at the true cause.

Some individuals with postcholecystectomy syndrome have an underlying motilitydisorder of the sphincter of Oddi, termed biliary dyskinesia, in which the sphincterfails to relax normally following ingestion of a meal. The diagnosis can beestablished in specialized centers by endoscopic biliary manometry. In establishedcases of biliary dyskinesia, endoscopic retrograde sphincterotomy is usually effectivein relieving the symptoms.

Medication

Contributor Information and DisclosuresAuthorDouglas M Heuman, MD, FACP, FACG, AGAF Chief of Hepatology, Hunter Holmes McGuire Department ofVeterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology,Virginia Commonwealth University School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: AmericanAssociation for the Study of Liver Diseases, American College of Physicians, American GastroenterologicalAssociation

Disclosure: Received grant/research funds from Novartis for other; Received grant/research funds from Bayer forother; Received grant/research funds from Otsuka for none; Received grant/research funds from Bristol MyersSquibb for other; Received none from Scynexis for none; Received grant/research funds from Salix for other;Received grant/research funds from MannKind for other.

Coauthor(s)Jeff Allen, MD Assistant Professor, Department of Surgery, University of Louisville

Disclosure: Nothing to disclose.

Anastasios A Mihas, MD, DMSc, FACP, FACG Professor, Department of Medicine, Division ofGastroenterology, Virginia Commonwealth University School of Medicine; Consulting Staff, VirginiaCommonwealth 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

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Anastasios A Mihas, MD, DMSc, FACP, FACG is a member of the following medical societies: AmericanAssociation for the Study of Liver Diseases, American College of Gastroenterology, American College ofPhysicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, SigmaXi, Southern Society for Clinical Investigation, American Federation for Clinical Research, GastroenterologyResearch Group


Chief EditorJulian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology,American College of Physicians, American Gastroenterological Association, American Geriatrics Society,American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law,Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for SocialResponsibility


AcknowledgementsFirass Abiad, MD Head of Division, General and Laparoscopic Surgery, Specialized Medical Center Hospital,Saudi Arabia


BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College ofMedicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of LiverDiseases, American College of Gastroenterology, American Gastroenterological Association, and AmericanSociety for Gastrointestinal Endoscopy


David Eric Bernstein, MD Director of Hepatology, North Shore University Hospital; Professor of ClinicalMedicine, Albert Einstein College of Medicine

David Eric Bernstein, MD is a member of the following medical societies: American Association for the Study ofLiver Diseases, American College of Gastroenterology, American College of Physicians, AmericanGastroenterological Association, and American Society for Gastrointestinal Endoscopy


Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine,Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western ReserveUniversity School of Medicine

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David FM Brown, MD Associate Professor, Division of Emergency Medicine, Harvard Medical School; ViceChair, Department of Emergency Medicine, Massachusetts General Hospital

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William K Chiang, MD Associate Professor, Department of Emergency Medicine, New York University Schoolof Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center

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Alfred Cuschieri, MD, ChM, FRSE, FRCS, Head, Professor, Department of Surgery and Molecular Oncology,University of Dundee, UK


Imad S Dandan, MD Consulting Surgeon, Department of Surgery, Trauma Section, Scripps Memorial Hospital

Imad S Dandan, MD is a member of the following medical societies: American Association for the Surgery ofTrauma, American College of Surgeons, American Medical Association, American Trauma Society, CaliforniaMedical Association, and Society of Critical Care Medicine


David Greenwald, MD Associate Professor of Clinical Medicine, Fellowship Program Director, Department ofMedicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine

David Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, American College ofGastroenterology, American College of Physicians, American Gastroenterological Association, American Societyfor Gastrointestinal Endoscopy, and New York Society for Gastrointestinal Endoscopy


Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of EmergencyMedicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine,Martin Luther King Jr/Drew Medical Center


Faye Maryann Lee, MD Staff Physician, Department of Emergency Medicine, New York University/Bellevue


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Assaad M Soweid, MD, FASGE, FACG Associate Professor of Clinical Medicine, Endosonography andAdvanced Therapeutic Endoscopy, Director, EndoscopyBronchoscopy Unit, Division of Gastroenterology,Department of Internal Medicine, American University of Beirut Medical Center, Lebanon

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