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Gallstones and gallbladder disease

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of gallstones.

Alternative Names

Cholecystitis; Choledocholithiasis; Bile duct stones

Treatment

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.

• Expectant management ("wait and see")
• Nonsurgical removal of the stones
• Surgical removal of the gallbladder

Expectant Management

Guidelines from the American College of Physicians state that when a person has no symptoms, the risks of both surgical and nonsurgical treatment for gallstones outweigh the benefits. Experts suggest a wait-and-see approach for such patients, which they have termed expectant management. Exceptions to this policy are those at risk for complications from gallstones, including the following:

• People at risk for gallbladder cancer
• Pima Native Americans
• Patients with stones larger than 3 cm

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 asymptomatic or low-risk individuals. Gallstones almost never spontaneously disappear, except sometimes when they are formed under special circumstances, such as pregnancy or sudden weight loss. At some point, then, the stones may cause pain, complications, or both and require treatment. Some studies suggest that the patient's age at diagnosis may be a factor in the possibility of future surgery. The probabilities are as follows:

• 15% likelihood of future surgery at 70 years old
• 20% at 50 years old
• 30% at 30 years old

The slight risk of developing gallbladder cancer might encourage young adults who are asymptomatic to have their gallbladders removed.

Gallstones and Severe Abdominal Pain

Gallstones are the most common cause for hospital admissions of patients with severe abdominal pain. Diagnostic tests are performed and, depending on results, the approach may be as follows.

Normal Test Results and No Severe Pain or Complications. If the patient has no fever or underlying serious medical problems and shows no signs of severe pain or complications, and if laboratory tests are normal, then the patients may be discharged with oral antibiotics and pain relievers.

Gallstones and Presence of Pain (Biliary Colic) but No Infection. Patients with pain and tests that indicate gallstones but who do not show signs of inflammation or infection have the following options:

• Intravenous pain killers are administered for severe pain. Such drugs include meperidine (Demerol) or the potent NSAID ketorolac (Acular, Toradol). Ketorolac should not be used for patients who are likely to need surgery. They can cause nausea, vomiting, and drowsiness. Opioids, such as morphine, may have fewer adverse effects, but some doctors avoid them for gallbladder disease.
• They may electively choose to have the gallbladder removed (called cholecystectomy) at their convenience.
• A minority of such patients may be candidates for a stone-breaking technique called lithotripsy (the treatment works best on solitary stones that are less than 2 cm in diameter.)
• Drug therapy for gallstones is available for some patients who are unwilling to undergo surgery or who have serious medical problems that increase the risks of surgery. Recurrence rates are high with nonsurgical options. The introduction of laparoscopic cholecystectomy has greatly reduced the use of nonsurgical therapies. Note: Drugs treatments are generally inappropriate for patients who have acute gallbladder inflammation or common bile duct stones since delaying or avoiding surgery could be very hazardous in these cases.

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:

• Fasting.
• Intravenous fluids and oxygen therapy.
• Intravenous painkillers, usually meperidine (Demerol). Potent NSAIDs, usually indomethacin, may be particularly useful. Indomethacin, for example, can reduce pain and inflammation and improve emptying actions of the gallbladder. (Some doctors believe morphine should be avoided for gallbladder disease.)
• Intravenous antibiotics. These are administered if the patient shows signs of infection, including fever or an elevated white blood cell count, or in patients without such signs who do not improve after 12 to 24 hours.

Surgery to remove the gallbladder (called cholecystectomy) is nearly always indicated in people with acute cholecystitis. The most common procedure is now laparoscopy, a less invasive technique than open cholecystectomy (which involves a wide abdominal incision). Timing can be within hours to weeks after the acute episode, depending on the severity of the condition.

Gallstone-Associated Pancreatitis. Patients who have developed gallstone-associate pancreatitis almost always require surgery, either laparoscopic or open cholecystectomy.

Common Duct Stones. If noninvasive diagnostic tests suggest obstruction from common duct stones, the doctor performs a procedure called endoscopic retrograde cholangiopancreatography (ERCP) to confirm the diagnosis and remove stones. This technique is used urgently 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.)

• Review Date: 6/12/2006
• Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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