An in-depth report on the causes, diagnosis, treatment, and prevention of gallstones.
Cholecystitis; Choledocholithiasis; Bile duct stones
Acute pain from gallstones and gallbladder disease is usually treated in the hospital, where diagnostic procedures are performed to rule out other conditions and complications. There are three approaches to gallstone treatment:
Guidelines from the American College of Physicians state that when a person has no symptoms, the risks of both surgical and nonsurgical treatments for gallstones outweigh the benefits. Experts suggest a wait-and-see approach, which they have termed expectant management, for these patients. Exceptions to this policy are people who cholangiography shows are at risk for complications from gallstones, including the following:
One study reported that very small gallstones increase the risk for acute pancreatitis, a serious condition. Some experts therefore believe that gallstones smaller than 5 mm warrant immediate surgery.
There are some minor risks with expectant management for people who do not have symptoms or who are at low risk. Gallstones almost never spontaneously disappear, except sometimes when they are formed under special circumstances, such as pregnancy or sudden weight loss. At some point, the stones may cause pain, complications, or both, and require treatment. Some studies suggest the patient's age at diagnosis may be a factor in the possibility of future surgery. The probabilities are as follows:
The slight risk of developing gallbladder cancer might encourage young adults who do not have symptoms to have their gallbladder removed.
Gallstones are the most common cause for emergency room and hospital admissions of patients with severe abdominal pain. Many other patients experience milder symptoms. Results of diagnostic tests and the exam will guide the treatment, as follows:
Normal Test Results and No Severe Pain or Complications. Patients with no fever or serious medical problems who show no signs of severe pain or complications and have normal laboratory tests may be discharged from the hospital with oral antibiotics and pain relievers.
Gallstones and Presence of Pain (Biliary Colic) but No Infection. Patients who have pain and tests that indicate gallstones, but who do not show signs of inflammation or infection have the following options:
Acute Cholecystitis (Gallbladder Inflammation). The first step if there are signs of acute cholecystitis is to "rest" the gallbladder in order to reduce inflammation. This involves the following treatments:
People with acute cholecystitis almost always need surgery to remove the gallbladder. The most common procedure now is laparoscopy, a less invasive technique than open cholecystectomy (which involves a wide abdominal incision). Surgery may be done within hours to weeks after the acute episode, depending on the severity of the condition.
Gallstone-Associated Pancreatitis. Patients who have developed gallstone-associated pancreatitis almost always have a cholecystectomy during the initial hospital admission or very soon afterwards. For gallstone pancreatitis, immediate surgery may be better than waiting up to 2 weeks after discharge, as current guidelines recommend. Patients who delay surgery experience a high rate of recurrent attacks before their surgery.
Common Duct Stones. If noninvasive diagnostic tests suggest obstruction from common duct stones, the doctor will perform endoscopic retrograde cholangiopancreatography (ERCP) to confirm the diagnosis and remove stones. This technique is used along with antibiotics if infection is present in the common duct (cholangitis). In most cases, common duct stones are discovered during or after gallbladder removal.
Common bile duct stones pose a high risk for complications and nearly always warrant treatment. There are various options available. It is not clear yet which one is best.
Experts are currently debating the choice between laparoscopy and ERCP. Many surgeons believe that laparoscopy is becoming safe and effective, and should be the first choice. Still, laparoscopy for common bile duct stones should only be performed by surgeons who are experienced in this technique.
Oral drugs used to dissolve gallstones and lithotripsy (alone or in combination with other drugs) gained popularity in the 1990s. Oral medications have lost favor with the increased use of laparoscopy, but they may still have some value in specific circumstances.
Oral Dissolution Therapy. Oral dissolution therapy uses bile acids in pill form to dissolve gallstones, and may be used in conjunction with lithotripsy, although both techniques are rarely used today. Ursodiol (ursodeoxycholic acid, Actigal, UDCAl) and chenodiol (Chenix) are the standard oral bile acid dissolution drugs. Most doctors prefer ursodeoxycholic acid, which is considered to be one of the safest common drugs. Long-term treatment appears to notably reduce the risk of biliary pain and acute cholecystitis. The treatment is only moderately effective, however, because gallstones return in the majority of patients.
Patients most likely to benefit from oral dissolution therapy are those who have small stones (less than 1.5 cm in diameter) with a high cholesterol content.
Patients who probably will not benefit from this treatment include obese patients and those with gallstones that are calcified or composed of bile pigments.
Only about 30% of patients are candidates for oral dissolution therapy. The number may actually be much lower, because compliance is often a problem. The treatment can take up to 2 years and can cost thousands of dollars per year.
Contact Dissolution Therapy. Contact dissolution therapy requires the injection of the organic solvent methyl tert-butyl ether (MTBE) into the gallbladder to dissolve gallstones. This is a technically difficult and hazardous procedure, and should be performed only by experienced doctors in hospitals where research on this treatment is being done. Preliminary studies indicate that MTBE rapidly dissolves stones -- the ether remains liquid at body temperature and dissolves gallstones within 5 - 12 hours. Serious side effects include severe burning pain.
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