Cholelithiasis
Alternative names:
gallstones
Treatment:
Since the first recognized case of cholelithiasis over 1500
years ago, numerous treatments have been used. These are primarily
medical and surgical.
Bile salts taken orally
may dissolve gallstones in those with a functioning gallbladder,
but the process may take 2 years or longer, and stones may
recur after the therapy is discontinued.
Medical dissolution, using both high-dose and low-dose chenodeoxycholic
acids (CDCA, chenediol) was an approach investigated in the
early 1980s. However, it was successful in only around 14%
of cases, required a long period of administration as well
as a lifetime of maintenance therapy. Urodeoxycholic acid
(UDCA, ursodiol), a more contemporary medical therapy, is
successful in only 40% of cases. Both CDCA and UDCA therapies
are useful only for gallstones formed from cholesterol.
Other chemical methods include contact dissolution in which
a catheter is passed through the abdominal wall and into the
gallbladder and methyl tert-butyl ether, a volatile chemical,
is then instilled. This chemical rapidly dissolves cholesterol
stones but potential toxicity, stone recurrence, and other
complications limit its utility.
Electrohydraulic shock wave lithotripsy (ESWL) has also
been employed to treat cholelithiasis. The principal underlying
this modality is that electromagnetically produced high-energy
shock waves, when focused on a specific point in a liquid
medium, can produce fragmentation. This approach was particularly
popular in the mid to late 1980s, when some studies found
it to clear gallstones in up to 60% of patients. However,
its application is limited if there are a large number of
stones present, if the stones are very large, or in the presence
of acute cholecystitis or cholangitis. It can also be used
in association with UDCA to improve its effect.
Despite these medical approaches, modern advances in surgical
management have revolutionized the treatment of cholelithiasis.
In general, surgery is indicated for symptomatic disease only.
In the past, open cholecystectomy
was the usual procedure for uncomplicated cases. This operation
necessitated a medium to large abdominal surgical incision
just below the right lower rib in order to gain access to
the gallbladder. After this operation, a patient typically
spent 3-5 days in the hospital recovering.
However, in the early to mid 1980s, a new minimally invasive
technique termed laparoscopic cholecystectomy
was introduced which used small incisions and camera guidance
in order to remove the gallbladder containing the symptomatic
stones. Currently, laparoscopic cholecystectomy
is the gold standard for care of symptomatic cholelithiasis
and is one of the most common operations performed in hospitals
today. Using this approach, a patient with symptomatic cholelithiasis
may have their gallbladder removed in the morning and be discharged
from the hospital on the same evening or the next morning.
In addition, gallstones blocking the common bile
duct may be visualized and removed during the laparoscopic
procedure. The impact of this surgical treatment method has
supplanted medical approaches to the treatment of gallstones,
because it has a complication rate of less than 1%.
Expectations (prognosis):
Gallstones develop in many people without causing symptoms.
The chance of symptoms or complications resulting from cholelithiasis
is about 20%. With current surgical approaches, the outcome
is excellent with no recurrence of symptoms in over 99% of
individuals.
Complications:
Calling your health care provider:
Call for an appointment with your health care provider if
symptoms of right upper quadrant abdominal
pain persist or recur, jaundice
develops, or other symptoms suggestive of cholelithiasis occur.
References:
1. Johnston, DE and Kaplan, MM. Pathogenesis
and treatment of gallstones. N Engl J Med, 328:412-21, 1993.
2. Ahmed, A, Cheung, RC, Keeffe, EB. Management
of gallstones and their treatment. Am Fam Physician, 61(6):1673-80,
2000.
3. Gadacz, TR. U.S. experience with laparoscopic
cholecystectomy. Am J Surg, 165:450, 1993.
4. Johnson, AB; Fink, AS. Alternative methods
for management of the complicated gallbladder. Seminars in
Laparoscopic Surgery, Jun, 5(2):115-20, 1998.
5. Dennison, AR; Azoulay, D; Oakley, N et
al. What should I do about my patient's gall stones? Postgraduate
Medical Journal, Dec, 71(842):725-9, 1995
Updated Date: 06/22/00
Updated by: James P. Dolan, MD Research Fellow
and Senior Resident in Surgery, University of California,
San Francisco
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