Gallstones start in the gallbladder, highlighted here in red. Treatment of gallstones ranges from watchful waiting to surgery.

© Sebastian Kaulitzki | Dreamstime

Our gallbladder—a pear-shaped organ that sits beneath the liver—has a simple function: to store and concentrate bile, a digestive enzyme made by the liver. Within the gallbladder, however, solid deposits known as gallstones can form, a condition that affects up to 9 million people in the U.S. each year. Among those who are afflicted, around 500,000 require gallbladder removal, or cholecystectomy. What are the various other options for gallstones treatment, whether symptoms are mild or have progressed to a “gallbladder attack“?

Gallstones Treatment: Watchful Waiting

Patients with asymptomatic (no symptoms yet) and uncomplicated gallstone disease may be managed with close monitoring. The risk of surgical complications outweighs the risk of gallstones complications. Around 1 in 4 asymptomatic patients will develop symptoms within 10 years. Once symptoms do develop, surgery is usually recommended.

Medical Treatment of Gallstones: 2 Options

Medical treatment is useful, as an alternative to surgery, in those who develop small gallstones (less than 1 cm in diameter). It is not suitable if there is acute pain, gallbladder inflammation, or cancer. Options include:

• Oral bile salt therapy (ursodeoxycholic acid): May be useful for cholesterol gallstones in those with an otherwise healthy gallbladder. Treatment is needed for more than six months but the success rate is less than 50 percent. In those for whom treatment is successful, recurrence occurs in 50 percent of cases over five years.
• Extracorporeal shockwave lithotripsy. More commonly used for kidney stones, this technique is rarely used for gallstones. Shockwaves are used to break gallstones into small pieces in the hope that they can be passed or dissolved with bile salt therapy. It works best in fit individuals with three or fewer small cholesterol stones and an otherwise normal gallbladder. A sedative is given to reduce discomfort during the procedure.

Gallstones Treatment: Surgical Options

Gallbladder removal, or cholecystectomy, is reserved for individuals with symptoms or with complications of gallstones along with those in high-risk groups who are fit enough for surgery. It involves the removal of the gallbladder and sometimes exploration of the common bile duct.

Indications for gallbladder removal include:

• Symptomatic stones
• Larger gallstones (over 2 cm diameter)
• Diseased gallbladder: Those with a gallbladder that is not filling or emptying normally, infected, or calcified (porcelain)
• Spinal cord injuries or sensory neuropathies affecting the abdomen
• Sickle cell anemia
• Cirrhosis of the liver and portal hypertension (high blood pressure in certain abdominal blood vessels)
• Diabetes
• Children (very rare)
• Transplant candidates.

Laparoscopic cholecystectomy, also known as “keyhole surgery,” is usually the first-line treatment, where available. It is suitable for small stones (under 1 cm) and if the gallbladder is otherwise healthy (fills and empties normally, and is not calcified).

Here the surgery is minimally invasive, with up to four small incisions made in the abdomen. The gallbladder is removed using a thin laparoscopic instrument. The surgery can be performed while the patient is under a general anesthetic. Day-patient surgery typically will apply to fit people. Normal activities can be resumed in about two weeks or so.

Open cholecystectomy, or open surgery, involves the gallbladder being removed through a 5- to 7-inch abdominal incision just under the right side of the ribcage. This is usually reserved for when the gallbladder is diseased (from inflammation, infection, or cancer), if you are overweight or pregnant, or if you have other abdominal symptoms that need to be explored, or if you have a bleeding disorder. It is a major surgery requiring a hospital stay of at least two days, and normal activities can be resumed in six weeks or so.

There are potential complications with cholecystectomy:

• Five to 10 percent of patients develop chronic diarrhea. This is usually mild and can be treated with over-the-counter medication, such as loperamide. More significant diarrhea can be treated with bile acid-binding resin, such as colestipol.
• Development of stones in bile duct, although this condition is rare.
• Postcholecystectomy syndrome: Chronic pain after surgery, the cause of which is often elusive.
• Lost gallstones. Occasionally gallstones are lost in the peritoneal (abdominal) cavity. These patients are usually followed up with ultrasound for 12 months.
• Damage to the common bile duct. This uncommon complication is more likely with laparoscopic removal.

Prevention of Gallstones

According to research, there are many risk factors for gallstones that you cannot change, but maintaining a healthy weight, exercising, and eating a healthy diet may reduce your risk.

Dietary changes might include these goals:

• Decreasing your intake of highly refined sugars, high fructose corn syrup, low-fiber foods, high-fat foods, and fast food.
• Increasing your intake of monounsaturated fats, including olive oil and fish, along with fiber, vegetables, fruit (vitamin C-rich foods), coffee, and moderate alcohol consumption.

For more information on gallstones treatment, see the following University Health News posts:

• “What Causes Gallstones?“
• “What Does a Gallbladder Attack Feel Like?“
• “How to Identify Gallbladder Pain: Gallstone Diagnosis and Treatment“
• “Gallbladder and Gallstones: How to Protect Yourself from Painful Attacks“