Cholelithiasis (gallstones)

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

symptomatic cholelithiasis

1st line – analgesia

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1st line –

analgesia

Treat biliary colic with a non-steroidal anti-inflammatory drug, such as diclofenac or indometacin.[1]

Paracetamol might be sufficient in individual cases.
For severe symptoms, use an opioid.
- The European Association for the Study of the Liver (EASL) recommends buprenorphine as a suitable option, because it appears to contract the sphincter of Oddi less than morphine.[1]

Primary options

paracetamol: oral: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; intravenous (<51 kg body weight): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; intravenous (≥51 kg body weight): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)

diclofenac sodium: 75 mg intramuscularly once or twice daily when required

indometacin: 100 mg rectally twice daily when required

Secondary options

buprenorphine: consult specialist for guidance on dose

Consider – anti-spasmodic

Plus – cholecystectomy

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Plus –

cholecystectomy

Treatment recommended for ALL patients in selected patient group

If the patient has symptomatic gallbladder stones but does not have features of cholecystitis, offer the patient elective laparoscopic cholecystectomy.[10]

Surgery is indicated to prevent recurrence and serious complications such as pancreatitis and cholangitis.[1]
Offer day-case laparoscopic cholecystectomy, unless circumstances, or the clinical condition of the patient, warrant a hospital stay.[10]
Open laparotomy occasionally becomes necessary when laparoscopy is technically difficult (e.g. if it difficult to establish pneumoperitoneum, key anatomy is not clear, or there is concern for possible iatrogenic injury), or when patient-related factors complicate the surgery (e.g., inflammation, adhesions, intra-abdominal fat, or bleeding/untreated cogulopathy).[107]
There are no differences in mortality, complications, or operative times between laparoscopic and open cholecystectomy.[1][33][108] The benefit of laparoscopic cholecystectomy is the reduced length of hospital stay and shorter recovery time.[1][33][108]

Do not routinely give antibiotic prophylaxis for elective laparoscopic cholecystectomy.[1]

Litholysis using bile acids alone or in combination with extracorporeal shock wave lithotripsy cannot be recommended as an alternative to cholecystectomy because symptomatic stones recur in approximately one third of patients.[1][109]

For patients with features of acute cholecystitis, see Acute cholecystitis.

choledocholithiasis with or without symptoms

1st line – bile duct clearance and laparoscopic cholecystectomy

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1st line –

bile duct clearance and laparoscopic cholecystectomy

If your patient has documented common bile duct stones (whether symptomatic or asymptomatic), offer bile duct clearance and laparoscopic cholecystectomy.[1][10]

Without this, there is a significant risk of complications such as jaundice, cholangitis, and pancreatitis, even in patients with asymptomatic choledocholithasis.[1]

There are two options available to clear the bile duct and evidence suggests similar outcomes:[1][10][105][106] [ ] [Evidence B]

Via endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy and stone extraction
OR
Surgically with laparoscopic common bile duct exploration at the same time as laparoscopic cholecystectomy.

ERCP

ERCP with biliary sphincterotomy and stone extraction can be done either before or at the same time as laparoscopic cholecystectomy.[10]

If ERCP is done first, subsequent laparoscopic cholecystectomy is needed as the definitive treatment to prevent obstructive complications such as acute cholangitis, hepatic abscess, or pancreatitis.[111][112] If your patient has simultaneous gallbladder and bile duct stones, early laparoscopic cholecystectomy should generally follow as soon as any anaesthetic or surgical issues are resolved, 24 to 72 hours after ERCP and stone extraction.[1][113]
A Cochrane review (5 RCTs, n=517) compared the benefits and harms of this two-stage approach (pre-operative endoscopic sphincterotomy followed by later laparoscopic cholecystectomy) versus a laparoscopic-endoscopic ‘rendezvous’ procedure that combines the two techniques in a single-stage operation. The authors concluded there was insufficient evidence to determine any difference in morbidity and mortality between the two approaches. The single stage laparoscopic-endoscopic procedure may have longer operating times but reduces the overall length of hospital stay; no firm conclusions could be drawn.[105]

ERCP may require various lithotripsy modalities or papillary balloon dilation. For difficult common bile duct stones, an experienced ERCP endoscopist might use a single-operator cholangioscopy system (‘scope within a scope’), either first-line or after unsuccessful standard ERCP. This allows direct visual examination of the biliary ducts and lithotripsy to clear the stones.[114]

Laparoscopic common bile duct exploration

Though technically more difficult, where expertise is available laparoscopic common bile duct exploration is as effective as ERCP performed prior to or after cholecystectomy with regards to stone clearance.[106][105]

A Cochrane review of surgical versus endoscopic treatment to clear bile duct stones included 5 RCTs (n=580) comparing the benefits and harms of a single laparoscopic procedure combining bile duct exploration and cholecystectomy versus a two-step approach of laparoscopic cholecystectomy and either pre- or post-operative ERCP to clear the bile duct. No significant differences in mortality, morbidity, or the number of people with retained stones were found between the two approaches.[10][105] [ ] [Evidence B]

Choice of procedure to clear the bile duct

In practice, the decision on whether to proceed with bile duct clearance via ERCP or laparoscopic common bile duct exploration is often guided by local availability and expertise, along with imaging appearances of duct size, the number of stones present, and their location.[97]

For those at intermediate risk of a common bile duct stone (abnormal liver biochemistry with more modest bilirubin elevations; biliary pancreatitis; and age >55 years), initial cholecystectomy with intraoperative cholangiography and common bile duct exploration may shorten hospitalisation without increasing complications.[97][115]
In practice, you should also consider laparoscopic common bile duct exploration if your patient has surgically altered anatomy (e.g., gastric surgery) or if ERCP fails to clear the bile duct.[116]

If your patient is not a candidate for surgery and ERCP fails to clear the bile duct, consider referral to a specialist hepatobiliary service for consideration of long-term biliary stenting.[27][112]

For patients with features of acute cholecystitis or acute cholangitis, see Acute cholecystitis and Acute cholangitis.

Plus – analgesia

Back

Plus –

analgesia

Treatment recommended for ALL patients in selected patient group

If your patient is symptomatic, treat biliary colic with a non-steroidal anti-inflammatory drug, such as diclofenac or indometacin.[1]

Paracetamol might be sufficient in individual cases.
For severe symptoms, use an opioid.
- The European Association for the Study of the Liver (EASL) recommends buprenorphine as a suitable option, because it appears to contract the sphincter of Oddi less than morphine.[1]

Primary options

diclofenac sodium: 75 mg intramuscularly once or twice daily when required

indometacin: 100 mg rectally twice daily when required

Secondary options

buprenorphine: consult specialist for guidance on dose

Consider – anti-spasmodic

2nd line – temporary stenting prior to definitive biliary clearance

Consider – analgesia

Back

Consider –

analgesia

Additional treatment recommended for SOME patients in selected patient group

Assess your patient’s need for analgesia on a case-by-case basis while the biliary pain is settling down. If the stent is draining effectively, pain should resolve within 24 to 36 hours. Strong analgesia is generally not continued beyond a few days.

If your patient is symptomatic, treat biliary colic with a non-steroidal anti-inflammatory drug, such as diclofenac or indometacin.[1]

Paracetamol might be sufficient in individual cases.
For severe symptoms, use an opioid.
- The European Association for the Study of the Liver (EASL) recommends buprenorphine as a suitable option, because it appears to contract the sphincter of Oddi less than morphine.[1]

Primary options

diclofenac sodium: 75 mg intramuscularly once or twice daily when required

indometacin: 100 mg rectally twice daily when required

Secondary options

buprenorphine: consult specialist for guidance on dose

ONGOING

asymptomatic cholelithiasis

1st line – observation

Back

1st line –

observation

Do not treat asymptomatic gallbladder stones found incidentally in a patient with a normal gallbladder and normal biliary tree.[1][10]

Prophylactic cholecystectomy might be considered in asymptomatic individuals:[33]
- With a heightened risk of developing gallbladder carcinoma (e.g., with gallstones >3 cm or a partially calcified 'porcelain' gallbladder)
- Whose risk of complications is high (e.g., patients with sickle cell disease).[2][28]

Do not routinely offer prophylactic cholecystectomy for severely obese patients undergoing wieght loss surgery, though concomitant cholecystectomy in symptomatic patients is safe and acceptable.[1][110]

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Cholelithiasis (gallstones)

Treatment algorithm

symptomatic cholelithiasis

analgesia

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

anti-spasmodic

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

cholecystectomy

choledocholithiasis with or without symptoms

bile duct clearance and laparoscopic cholecystectomy

ERCP

Laparoscopic common bile duct exploration

Choice of procedure to clear the bile duct

analgesia

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

anti-spasmodic

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

temporary stenting prior to definitive biliary clearance

analgesia

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

asymptomatic cholelithiasis

observation