Patient selection for the nonsurgical treatment of gallstone disease
- 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 and Hepatology
- Section Editor — General Hepatology; 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 of medical management of gallstone disease has decreased in recent years, particularly since the introduction of laparoscopic cholecystectomy. Cholecystectomy is preferred because of its reduced cost, definitive nature, and safety [1,2]. The laparoscopic approach has been associated with a significant increase in the number of cholecystectomies being performed in the United States each year, indicative of both its acceptability to patients and popularity with surgeons.
Nevertheless, medical management may be an alternative to cholecystectomy in selected patients with symptomatic gallstone disease. Historically, three non-surgical approaches have been described:
- Oral bile salt therapy (primarily ursodeoxycholic acid)
- Contact dissolution
- Extracorporeal shockwave lithotripsy
Of these, only oral dissolution therapy remains a practical clinical approach for a small subset of patients with cholesterol gallstone disease who are not surgical candidates. Contact dissolution therapy is no longer used due to concerns about the safety of methyl tert butyl ether (MTBE), the primary dissolution agent used, as well as the invasiveness of this procedure. Extracorporeal shock-wave lithotripsy has also fallen out of favor but may be used in association with oral dissolution therapy.
This topic will review the selection of patients for nonsurgical treatment of gallstone disease. The methods used for the nonsurgical treatment of gallstones as well as the surgical approaches to patients with gallstones are discussed elsewhere. (See "Nonsurgical treatment of gallstones" and "Open cholecystectomy" and "Laparoscopic cholecystectomy".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Darzi A, Geraghty JG, Williams NN, et al. The pros and cons of laparoscopic cholecystectomy and extracorporeal shock wave lithotripsy in the management of gallstone disease. Ann R Coll Surg Engl 1994; 76:42.
- Portincasa P, van de Meeberg P, van Erpecum KJ, et al. An update on the pathogenesis and treatment of cholesterol gallstones. Scand J Gastroenterol Suppl 1997; 223:60.
- Tomida S, Abei M, Yamaguchi T, et al. Long-term ursodeoxycholic acid therapy is associated with reduced risk of biliary pain and acute cholecystitis in patients with gallbladder stones: a cohort analysis. Hepatology 1999; 30:6.
- Testoni PA, Caporuscio S, Bagnolo F, Lella F. Idiopathic recurrent pancreatitis: long-term results after ERCP, endoscopic sphincterotomy, or ursodeoxycholic acid treatment. Am J Gastroenterol 2000; 95:1702.
- Caroli A, Del Favero G, Di Mario F, et al. Computed tomography in predicting gall stone solubility: a prospective trial. Gut 1992; 33:698.
- Petroni ML, Jazrawi RP, Grundy A, et al. Prospective, multicenter study on value of computerized tomography (CT) in gallstone disease in predicting response to bile acid therapy. Dig Dis Sci 1995; 40:1956.
- Hofmann AF. Primary and secondary prevention of gallstone disease: implications for patient management and research priorities. Am J Surg 1993; 165:541.
- Maringhini A, Ciambra M, Baccelliere P, et al. Biliary sludge and gallstones in pregnancy: incidence, risk factors, and natural history. Ann Intern Med 1993; 119:116.
- Shiffman ML, Keith FB, Moore EW. Pathogenesis of ceftriaxone-associated biliary sludge. In vitro studies of calcium-ceftriaxone binding and solubility. Gastroenterology 1990; 99:1772.
- Leitzmann MF, Giovannucci EL, Rimm EB, et al. The relation of physical activity to risk for symptomatic gallstone disease in men. Ann Intern Med 1998; 128:417.
- Valdivieso V, Covarrubias C, Siegel F, Cruz F. Pregnancy and cholelithiasis: pathogenesis and natural course of gallstones diagnosed in early puerperium. Hepatology 1993; 17:1.
- Quigley EM, Marsh MN, Shaffer JL, Markin RS. Hepatobiliary complications of total parenteral nutrition. Gastroenterology 1993; 104:286.
- Marks JW, Stein T, Schoenfield LJ. Natural history and treatment with ursodiol of gallstones formed during rapid loss of weight in man. Dig Dis Sci 1994; 39:1981.
- Sitzmann JV, Pitt HA, Steinborn PA, et al. Cholecystokinin prevents parenteral nutrition induced biliary sludge in humans. Surg Gynecol Obstet 1990; 170:25.
- Dawes LG, Muldoon JP, Greiner MA, Bertolotti M. Cholecystokinin increases bile acid synthesis with total parenteral nutrition but does not prevent stone formation. J Surg Res 1997; 67:84.
- Zoli G, Ballinger A, Healy J, et al. Promotion of gallbladder emptying by intravenous aminoacids. Lancet 1993; 341:1240.
- Sugerman HJ, Brewer WH, Shiffman ML, et al. A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss. Am J Surg 1995; 169:91.
- Shiffman ML, Sugerman HJ, Kellum JM, et al. Gallstone formation after rapid weight loss: a prospective study in patients undergoing gastric bypass surgery for treatment of morbid obesity. Am J Gastroenterol 1991; 86:1000.
- Wudel LJ Jr, Wright JK, Debelak JP, et al. Prevention of gallstone formation in morbidly obese patients undergoing rapid weight loss: results of a randomized controlled pilot study. J Surg Res 2002; 102:50.
- Pereira SP, Hussaini SH, Kennedy C, Dowling RH. Gallbladder stone recurrence after medical treatment. Do gallstones recur true to type? Dig Dis Sci 1995; 40:2568.
- Tudyka J, Wechsler JG, Kratzer W, et al. Gallstone recurrence after successful dissolution therapy. Dig Dis Sci 1996; 41:235.
- Rubin RA, Kowalski TE, Khandelwal M, Malet PF. Ursodiol for hepatobiliary disorders. Ann Intern Med 1994; 121:207.
- Tsumita R, Sugiura N, Abe A, et al. Long-term evaluation of extracorporeal shock-wave lithotripsy for cholesterol gallstones. J Gastroenterol Hepatol 2001; 16:93.
- Adamek HE, Buttmann A, Weber J, Riemann JF. Can aspirin prevent gallstone recurrence after successful extracorporeal shockwave lithotripsy? Scand J Gastroenterol 1994; 29:355.