Patient selection for the nonsurgical treatment of gallstone disease

INTRODUCTION

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 "Dissolution therapy for the treatment of gallstones" and "Open cholecystectomy" and "Laparoscopic cholecystectomy: Techniques".)