Typically, silent gallstones are left untreated, but surgery may be considered for individuals deemed to have a high risk of gallbladder cancer or conditions that increase their risk of gallstone complications, such as sickle cell disease, a weakened immune system, or an upcoming weight loss surgery (Shaffer 2018; Fogel 2016). Dietary, lifestyle, and natural medicine interventions may help people with silent gallstones avoid progressing to a symptomatic stage of gallstone disease (Shabanzadeh 2016; Di Ciaula 2017).
For all forms of symptomatic gallstone disease, surgery is the mainstay of conventional treatment.
Gallbladder Removal (Cholecystectomy)
Acute biliary pain from gallstones, in the absence of complications, can be treated with pain relievers (Tanaja 2018). Because recurrence is common, surgical removal of the gallbladder, known as cholecystectomy, is widely recommended following an acute episode of gallstone cholecystitis (Jones, Ghassemzadeh 2018; Sinha 2002; Acar 2017). Cholecystectomy is also the treatment of choice for chronic cholecystitis (inflammation of the gallbladder) (Jones, Ferguson 2018).
Laparoscopic cholecystectomy, which uses a video camera inserted via small punctures in the abdominal wall, is preferred for its shorter in-hospital time, shorter post-surgical recovery time, and lower rates of certain complications. Nonetheless, open cholecystectomy, involving a larger cut in the abdominal wall, may be necessary in some cases (Shaffer 2018; Zakko 2018; Gomes 2017). About half of individuals who undergo cholecystectomy experience digestive symptoms such as loose stools, gas, and bloating following surgery; these symptoms usually improve over time without treatment (Zakko 2018).
The bile salt ursodeoxycholic acid (Actigall), also known as ursodiol, is a naturally-occurring bile salt that decreases liver secretion of cholesterol, lowers cholesterol saturation in bile, and promotes the dissolving of cholesterol stones (Portincasa 2012). Ursodeoxycholic acid usually relieves symptoms within two to three months, but may take years to completely dissolve gallstones (Zakko 2018; Jones, Ghassemzadeh 2018). It is only effective for treating small, cholesterol-rich, calcium-free stones in people with a functioning gallbladder and bile duct. Ursodeoxycholic acid has been reported to have a 90% success rate for dissolving stones with these characteristics; however, the recurrence rate has been reported to be as high as 30–50% within five years after treatment. Because of its slow action and high post-treatment recurrence rate, ursodeoxycholic acid is not widely recommended, and its use is generally reserved for those who cannot undergo surgery (Portincasa 2012; Portincasa 2017; Goral 2016). It is also sometimes prescribed after weight loss surgery to reduce the accompanying risk of gallstone formation (Magouliotis 2017). Mild, temporary diarrhea is the main side effect of ursodeoxycholic acid (Zakko 2018).
Treatment of Gallstone Complications
In patients with gallstones in the common bile duct (choledocholithiasis), stone removal through a combination procedure called endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy (cutting of the muscular sphincter that controls bile flow into the small intestine) is considered the best option and is the most commonly used approach. Extra interventions such as stone fragmentation (lithotripsy), balloon dilation of the opening of the common bile duct into the small intestine, or propping open (stenting) the common bile duct may be required along with ERCP if the gallstone is large, impacted, or trapped in front of an obstruction (Molvar 2016; Shaffer 2018; Sakai 2016). Many patients with a stone in a bile duct also have stones in the gallbladder; for these individuals, cholecystectomy is generally performed after ERCP (Shaffer 2018; Baloyiannis 2015).
Bile duct infection (cholangitis) and gallstone pancreatitis are dangerous complications that require immediate attention, including intravenous fluids, pain relievers, and antibiotics. ERCP, stone removal, and sphincterotomy may be needed, and cholecystectomy will likely be recommended during the same hospital stay or at a later time (Shaffer 2018; Stinton 2012). Gallstone-related bowel obstruction (ileus) also requires urgent medical treatment with surgical stone removal and repair of the intestinal wall, and sometimes cholecystectomy either as part of the same procedure or later (Turner 2018).
Health Effects of Cholecystectomy
After cholecystectomy, patients may experience short-term digestive problems, such as diarrhea, bloating, and abdominal pain (Altomare 2017; Zakko 2018). Although pre-surgery symptoms are effectively relieved in more than 90% of patients treated with cholecystectomy, a small number of patients develop a set of symptoms and findings collectively referred to as post-cholecystectomy syndrome (Jaunoo 2010). Dysfunction of the sphincter of Oddi, located at the opening of the common bile duct into the small intestine, is a cause in some cases of post-cholecystectomy syndrome, but more frequently the cause is an overlooked disorder outside of the biliary system, such as peptic ulcer, chronic pancreatitis, or irritable bowel syndrome, or is unknown (Tarnasky 2016; Jaunoo 2010; Shirah 2018). Cholecystectomy is also associated with long-term increased risk of weight gain and metabolic syndrome, gastritis, and deficiencies of fat soluble vitamins (ie, vitamins A, D, E and K) (Altomare 2017; Chen 2018).