Gallstone disease - Treatment

Treatment goals for gallstone disease

• Removal of gallstones (either the stones themselves from the bile ducts, or the gallbladder together with stones).
• Relief of clinical symptoms without surgical intervention (if there are contraindications to surgical treatment).
• Prevention of the development of complications, both immediate (acute cholecystitis, acute pancreatitis, acute cholangitis) and distant (gallbladder cancer).

The reasons for the main errors in the management of patients with cholelithiasis are the underestimation of repeated episodes of biliary colic as a serious indication for surgical treatment of the disease, which leads to the development of acute and chronic complications of cholelithiasis and high mortality of patients from cholelithiasis.

Indications for hospitalization

In the surgical hospital: recurrent biliary colic; acute and chronic cholecystitis and their complications; acute biliary pancreatitis. In the gastroenterological hospital:

• chronic calculous cholecystitis - for detailed examination and preparation for surgical or conservative treatment;
• exacerbation of cholelithiasis and the condition after cholecystectomy (chronic biliary pancreatitis, dysfunction of the sphincter of Oddi).

Duration of inpatient treatment: chronic calculous cholecystitis - 8-10 days, chronic biliary pancreatitis (depending on the severity of the disease) - 21-28 days.

Treatment includes diet therapy, medications, remote lithotripsy methods and surgery.

Non-drug treatment of gallstone disease

Diet therapy: at all stages, 4-6 meals a day are recommended, excluding foods that increase bile secretion, gastric and pancreatic secretion. Smoked foods, refractory fats, and irritating seasonings are excluded. The diet should include a large amount of plant fiber with the addition of bran, which not only normalizes intestinal peristalsis, but also reduces the lithogenicity of bile. Fasting for 2-3 days is necessary for biliary colic.

Drug treatment of gallstone disease

Oral litholytic therapy is the only effective conservative method of treating cholelithiasis.

In patients with cholelithiasis, a decrease in the pool of bile acids is observed. This fact served as an incentive to study the possibility of dissolving gallstones using oral administration of bile acids, the results of which were successful. The mechanism of litholytic action is not an increase in the content of bile acids, but a decrease in the level of cholesterol in bile. Chenodeoxycholic acid inhibits intestinal absorption of cholesterol and its synthesis in the liver. Ursodeoxycholic acid also reduces the absorption of cholesterol and inhibits the normal compensatory activation of cholesterol biosynthesis. When treated with these drugs, the secretion of bile acids does not change significantly, but a decrease in cholesterol secretion leads to desaturation of bile. In addition, ursodeoxycholic acid increases the time of cholesterol precipitation.

Drug treatment of gallstone disease

Surgical treatment of gallstone disease

In asymptomatic cholelithiasis, as well as in a single episode of biliary colic and infrequent painful episodes, a wait-and-see approach is most justified. If indicated, oral lithotripsy may be performed in these cases.

Indications for surgical treatment of cholecystolithiasis:

• the presence of large and small stones in the gallbladder, occupying more than 1/3 of its volume;
• the course of the disease with frequent attacks of biliary colic, regardless of the size of the stones;
• disabled gallbladder;
• cholelithiasis complicated by cholecystitis and/or cholangitis;
• combination with choledocholithiasis;
• cholelithiasis complicated by the development of Mirizzi syndrome;
• cholelithiasis complicated by dropsy, empyema of the gallbladder;
• cholelithiasis complicated by perforation, penetration, fistulas;
• cholelithiasis complicated by biliary pancreatitis;
• cholelithiasis accompanied by obstruction of the common gallbladder
• bile duct.

Surgical treatment of gallstone disease

Consultations with specialists regarding treatment

• Consultation with a surgeon - decision on surgical treatment of gallstone disease.

Further management

All patients with gallstone disease are subject to dispensary observation in outpatient and polyclinic conditions. It is especially necessary to carefully observe patients with asymptomatic stone carriage. A thorough clinical assessment of the anamnesis and physical signs is indicated. If any dynamics appear, a laboratory examination and ultrasound are carried out. Similar measures are carried out if there is a single episode of biliary colic in the anamnesis.

When conducting oral litholytic therapy, regular monitoring of the state of stones using ultrasound is necessary. In the case of therapy with chenodeoxycholic acid, monitoring of liver function tests is recommended once every 2-4 weeks.

Patient education

The patient should be informed about the nature of his disease and possible complications. A certain regimen and diet should be recommended. In case of oral litholytic therapy, the duration of treatment and the possibility of its failure should be justified. It is important to convince the patient of the need for timely planned surgery and to provide information about the possibility of its laparoscopic version.

Forecast

The effectiveness of conservative treatment is quite high: with proper selection of patients, complete dissolution of stones is observed after 18-24 months in 60-70% of patients, however, relapses of the disease are not uncommon.

Prevention

It is necessary to maintain an optimal BMI and sufficient level of physical activity. A sedentary lifestyle contributes to the formation of gallstones.

If rapid weight loss of the patient is expected (more than 2 kg/week for 4 weeks or more), ursodeoxycholic acid preparations may be prescribed at a dose of 8-10 mg/kg/day to prevent stone formation. Such an event prevents not only the formation of stones, but also cholesterol crystallization and an increase in the bile lithogenicity index.

In patients on long-term total parenteral nutrition, it is necessary to evaluate the advisability of intravenous administration of cholecystokinin at a dose of 58 ng/kg/day. Cholecystokinin prevents the development of the sludge phenomenon (predisposing to the formation of gallstones) in this group of seriously ill patients.

In some cases and only according to strict indications, laparoscopic cholecystectomy may be performed in the presence of asymptomatic stone carriage to prevent the development of clinical manifestations of gallstone disease or gallbladder cancer.

Indications for cholecystectomy in asymptomatic stone carriage:

• calcified ("porcelain") gallbladder;
• stones larger than 3 cm;
• upcoming long-term stay in a region with no qualified medical care;
• sickle cell anemia;
• the patient is about to undergo an organ transplant.

The best prevention of complications of cholelithiasis is timely surgical treatment.

Gallstone disease screening

Ultrasound is indicated for individuals with an increased risk of developing gallstone disease and gallbladder cancer: patients with an increased BMI, leading a sedentary lifestyle; patients complaining of discomfort in the right hypochondrium and epigastric regions, as well as all patients with risk factors for gallstone disease.

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