Dissolution therapy for the treatment of gallstones
- David Nunes, MD, FRCPI
David Nunes, MD, FRCPI
- Associate Professor of Medicine
- Boston University
- Section Editor
- Sanjiv Chopra, MD, MACP
Sanjiv Chopra, MD, MACP
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — General Hepatology
- Section Editor — Gallbladder and Biliary Tract Disease
- Professor of Medicine
- Harvard Medical School
- Senior Consultant in Hepatology
- James Tullis Firm Chief
- Beth Israel Deaconess Medical Center
The role for the medical management of gallstone disease has decreased since the introduction of laparoscopic cholecystectomy. Cholecystectomy remains the preferred method because of its reduced cost, definitive nature, safety, and increased convenience for the patient [1,2]. Furthermore, medical therapy of gallstones has been hampered by the high incidence of recurrent stones. As a result, interest in nonsurgical techniques for the management of gallstones has waned significantly.
Nevertheless, medical management using dissolution therapy may be an alternative to cholecystectomy in selected patients with symptomatic gallstone disease with a view either to eliminating stones or reducing the risk of further complications. In the past, the nonsurgical treatment of gallstones also included extracorporeal shock wave lithotripsy, though this is now rarely done. Successful treatment depends upon a functioning gallbladder and varies based upon the number, size, and composition of the stone(s). As a result, many symptomatic patients have stones that are not ideally suited to dissolution therapy, producing less than optimal results. The primary candidates for elective nonsurgical management of gallstones are patients who are symptomatic or are at high risk for developing symptomatic gallstone disease, but are not candidates for surgery. (See "Patient selection for the nonsurgical treatment of gallstone disease".)
Patients with acute gallstone-related disease who are not surgical candidates may require percutaneous cholecystostomy. Case series have also described placement of a cystic duct stent during endoscopic retrograde cholangiopancreatography in patients with gallstone-related disease (such as biliary colic, acute cholecystitis, acalculous cholecystitis, and gallstone pancreatitis) and serious comorbidities that precluded other approaches [3-8]. Although placement of such stents may be technically challenging, they can provide sufficient palliation until more definitive therapy can be performed. (See "Acalculous cholecystitis" and "Treatment of acute calculous cholecystitis".)
This topic will review dissolution therapy for the elective treatment of gallstones. Endoscopic sphincterotomy for gallstone-related disease without subsequent cholecystectomy, the selection of patients for nonsurgical treatment of gallstones, and laparoscopic cholecystectomy are discussed separately. (See "Endoscopic management of bile duct stones: Standard techniques and mechanical lithotripsy" and "Patient selection for the nonsurgical treatment of gallstone disease" and "Laparoscopic cholecystectomy".)
COMPOSITION OF GALLSTONES
Most medical therapies have been developed for the management of cholesterol-rich gallstones. Gallstones are composed of a mixture of cholesterol, calcium bilirubinate, proteins, and mucin. They are broadly classified as cholesterol, black pigment, or brown pigment stones, depending upon the predominant constituents, although most "cholesterol" stones have a mixed composition with small amounts of calcium and bilirubin salts. Black pigment stones result from hemolysis and consist primarily of calcium bilirubinate. Brown pigment stones are associated with bacterial and helminthic infection of the biliary system and are often found in the bile ducts in association with prior biliary manipulation or in association with biliary infestation. They may also occur as de novo common bile duct stones following cholecystectomy.
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