Management

In asymptomatic patient:

• no treatment is currently recommended (except for porcelain gallbladders due to its association with gallbladder cancer)
• there is no evidence that lifestyle modifications (e.g. - decreasing fatty food intake or increasing exercise) decreases or prevents the incidence of symptoms in people with asymptomatic gallstones
• if patient is undergoing major abdominal surgery, cholecystectomy may be offered (1)

In symptomatic cases:

• non surgical
  • analgesia, adequate hydration and antibiotics
    • diclofenac and an opioid (morphine or pethidine) used in combination or separately are effective
    • when pain cannot be managed or if the patient is otherwise unwell (eg sepsis), he or she should be referred to hospital as an emergency
  • there is no evidence of benefit from the use of non-surgical treatment methods in the definitive management of gallbladder stones (eg gallstone dissolution therapies, ursodeoxycholic acid or extracorporeal lithotripsy)
• surgical
  • cholecystectomy
    • laproscopic cholecystectomy is generally performed due to the shorter length of hospital stay, decreased pain, earlier return to work, and better cosmesis
      • can be performed as a day procedure
      • fat intolerance may develop in a small proportion of people after cholecystectomy
    • optimum time for surgery
      • there is no clear agreement on the timing of surgery
        • in biliary colic – a randomised controlled trial have shown that an average wait of about four months on the waiting list was associated with increased complication and hospital stay (when compared to early surgery within 24 hours of hospital admission)
        • in acute cholecystitis - although traditionally patients were managed conservatively to allow the inflammation to settle and perform laparoscopic cholecystectomy, it has been shown that early laproscopic surgery (within 7 days) was associated with decreased gallbladder related complications during the waiting time, decreased hospital stay and a lower morbidity.
    • early cholecystectomy is not recommended in patients with severe acute pancreatitis and those presenting during pregnancy (1,2)
  • percutaneous cholecystostomy
    • considered in an emergency situation in patients who are not suitable for cholecystectomy because of their general medical condition
    • cholecystectomy may be considered later with improvement of patients condition

NICE state (3):

• reassure people with asymptomatic gallbladder stones found in a normal gallbladder and normal biliary tree that they do not need treatment unless they develop symptoms
• offer laparoscopic cholecystectomy to people diagnosed with symptomatic gallbladder stones
• offer day-case laparoscopic cholecystectomy for people having it as an elective planned procedure, unless their circumstances or clinical condition make an inpatient stay necessary
• ofer early laparoscopic cholecystectomy (to be carried out within 1 week of diagnosis) to people with acute cholecystitis
• offer percutaneous cholecystostomy to manage gallbladder empyema when:
  • surgery is contraindicated at presentation and
  • conservative management is unsuccessful
• reconsider laparoscopic cholecystectomy for people who have had percutaneous cholecystostomy once they are well enough for surgery

Management of common bile duct stones (CBDS) (1,2)

• CBDS and in situ gallbladder
  • in this setting the clinician needs to consider both stone extraction and gallbladder removal
  • available treatment options include:
    • open cholecystectomy and common bile duct exploration
    • laparoscopic cholecystectomy with endoscopic stone extraction (ESE) or laparoscopic common bile duct exploration (LCBDE)
• CBDS and no gallbladder
  • biliary sphincterotomy and endoscopic stone extraction
• mechanical lithotripsy, extra-corporeal shock wave lithotripsy (ESWL) can be considered as well

Reference:

• (1) Gurusamy KS, Davidson BR. Gallstones. BMJ. 2014;348:g2669
• (2) Sanders G, Kingsnorth AN. Gallstones. BMJ. 2007;335(7614):295-9.
• (3) NICE (October 2014).Gallstone disease