- Expectant management (“wait and see”)
- Nonsurgical removal of the stones
- Surgical removal of the gallbladder
EXPECTANT MANAGEMENT OF ASYMPTOMATIC GALLSTONES
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:
- Those 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 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:
- 15% likelihood of future surgery at age 70
- 20% likelihood of future surgery at age 50
- 30% likelihood of future surgery at age 30
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:
- Intravenous painkillers for severe pain. Such drugs include meperidine (Demerol) or the potent NSAID ketorolac (Toradol). Ketorolac should not be used for patients who are likely to need surgery. These drugs can cause nausea, vomiting, and drowsiness. Opioids such as morphine may have fewer adverse effects, but some doctors avoid them in gallbladder disease.
- Elective gallbladder removal. Patients may electively choose to have their gallbladder removed (called cholecystectomy) at their convenience.
- Lithotripsy. A small number of 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. 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, and the introduction of laparoscopic cholecystectomy has greatly reduced the use of nonsurgical therapies. Note: Drug treatments are generally inappropriate for patients who have acute gallbladder inflammation or common bile duct stones, because delaying or avoiding surgery could be life threatening.
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:
- Intravenous fluids and oxygen therapy
- Strong painkillers, such as meperidine (Demerol). Potent NSAIDs, such as ketorolac, may also be particularly useful. 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 – 24 hours.
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.
MANAGEMENT OF COMMON BILE DUCT STONES
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.
- In the past, when common bile duct stones were suspected, the approach was open surgery (open cholecystectomy) and surgical exploration of the common bile duct. This required a wide abdominal incision.
- Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) is now the most frequently used procedure for detecting and managing common bile duct stones. The procedure involves the use of an endoscope (a flexible telescope containing a miniature camera and other instruments), which is passed down the throat to the bile duct entrance.
- Laparoscopic cholecystectomy also is increasingly being used for the detection and removal of common bile duct stones. This is an approach through the abdomen, but it uses small incisions instead of one large incision. It is used in combination with ultrasound or a cholangiogram (an imaging technique in which a dye is injected into the bile duct and moving x-rays are used to view any stones).
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.
Author: American Accreditation HealthCare Commission (www.urac.org)