Gallstones and Gallbladder Disease - Treatment

Highlights	Prevention	Managing Common Bile Duct Stones
Introduction	Diagnosis	Resources
Symptoms	Treatment	References
Prognosis	Surgery
Risk Factors	Lithotripsy and Dissolution Therapies

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

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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 three centimeters

One study reported that very small gallstones increase the risk for acute pancreatitis, a serious condition. Some experts therefore believe that gallstones smaller than five millimeters 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 two centimeters 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 non-surgical options. The introduction of laparoscopic cholecystectomy has greatly reduced the use of non-surgical 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.