Most individuals with gallstones are asymptomatic throughout their life and gallstones are found incidentally. The approach to the management of patients with gallstones depends upon the patient’s symptoms, imaging test findings, and whether complications are present. Gallstone complications include acute cholecystitis, cholangitis, gallstone pancreatitis, gallstone ileus, and Mirizzi syndrome. In general, patients with sludge or microlithiasis are managed the same as patients with gallstones. The term uncomplicated gallstone disease refers to stones in the gallbladder that are associated with biliary colic in the absence of complications.
●Patients with biliary colic
For patients with typical biliary colic and gallstones on imaging, we recommend cholecystectomy rather than expectant management (Grade 1B). Such patients are likely to have recurrent attacks and are at risk for complications. For patients who have had an isolated episode of biliary colic without complications and wish to avoid surgery, expectant management may be a reasonable alternative provided that the patient understands the risk of subsequent complications developing. It is important that patients who do not undergo cholecystectomy be educated about the symptoms of biliary colic and be instructed to seek medical attention if symptoms develop. Dissolution therapy is a reasonable alternative in patients who are not surgical candidates.
●Asymptomatic patients with incidental gallstones
For patients with incidental gallstones, we recommend expectant management rather than performing prophylactic cholecystectomy (Grade 1C). Waiting until a patient becomes symptomatic before performing cholecystectomy prevents unnecessary surgery since the majority of patients with incidental gallstones will never develop biliary colic. However, prophylactic cholecystectomy is indicated for patients who are at increased risk for gallbladder cancer. It may also have a role in the treatment of some patients with hemolytic disorders.
●Patients with atypical symptoms
For patients with atypical symptoms and gallstones, we suggest additional evaluation rather than cholecystectomy (Grade 2C). Such patients should be thoroughly evaluated for non-gallstone-related causes of their symptoms. Cholecystectomy is a reasonable alternative if a thorough evaluation for other causes of the patient’s symptoms is negative and if the patient has a symptomatic response to dissolution therapy.
