B Nonsurgical Therapy

1. Oral bile acid dissolution—In selected patients who have symptomatic gallbladder stones without complications and have mild and infrequent episodes of biliary pain, stone dissolution with UDCA may be employed. The patient must, however, be informed about the high risk of recurrent stones. UDCA reduces cholesterol saturation of bile and also produces a lamellar liquid crystalline phase in bile that allows dispersion of cholesterol from stones by physical-chemical means. In carefully selected patients with radiolucent stones smaller than 5-10 mm in diameter in a functioning gallbladder, complete dissolution can be achieved with UDCA in about 50% of patients. In general, 6-18 months of therapy are required to achieve complete dissolution of stones 5-10 mm in diameter, as gallstone dissolution occurs at a mean rate of 0.7-mm decrease in diameter per month. For good results within a reasonable time period, this therapy should be limited to radiolucent stones smaller than 5 mm in diameter. The dose of UDCA should be 10-15 mg/kg/day. Stones larger than 15 mm in size rarely dissolve. Pigment stones are not responsive to UDCA therapy. Recurrence of stones in 30-50% of patients within 3-5 years after stone dissolution have reduced the role of gallstone dissolution to patients who want to avoid or are unfit for cholecystectomy. A report from Japan that UDCA may reduce the risk of biliary pain independently from dissolution of the stones has not been confirmed in a recent study, which could not demonstrate a decrease of the incidence of biliary symptoms in gallstone patients awaiting elective cholecystectomy.

2.  Extracorporeal shock wave lithotripsy—Following the introduction of laparoscopic cholecystectomy, this nonsurgical therapeutic modality has been abandoned mainly because of high rates of stone recurrence (11-29% at 2 years, 60-80% at 10 years). Extracorporeal shock wave lithotripsy has maintained a limited role in the treatment of bile duct stones resistant to endoscopic extraction.

3.  Medical prophylaxis of cholesterol gallstone disease—

UDCA may prevent gallstone formation in obese patients during rapid weight loss. In patients who completed a 3-month, 520-kcal/day diet, UDCA at a dose of 600 mg/day proved highly effective in preventing gallstone formation; gallstones developed in only 3% of patients receiving UDCA compared with 28% receiving placebo. In a more recent study of stone prophylaxis by UDCA in obese patients treated by gastric banding, 500 mg/kg/day of UDCA reduced the risk of gallstone formation from 30% to 8% within a follow-up of 6 months. For prophylaxis of gallstone formation during rapid weight loss (> 1.5 kg/week) a minimal dose of UDCA of 500 mg/kg/day is recommended until constant body weight is attained.

4.  Symptomatic treatment of biliary colic—In general, combinations of analgesics with spasmolytic drugs are used for relief of pain. Paracetamol may be sufficient, but nonsteroidal antirheumatic drugs, such as diclofenac or indomethacin, may also be used in combination with N-butyl scopolamine. Often opiates such as pethidine or buprenorphine are required. Nitroglycerin may also be effective because it relaxes the sphincter of Oddi. The patient should be kept NPO (nothing by mouth). In case of vomiting, parenteral fluid and electrolyte replacement may be indicated.

Lammert F, Neubrand MW, Bittner R, et al. [S3-guidelines for diagnosis and treatment of gallstones. German Society for Digestive and Metabolic Diseases and German Society for Surgery of the Alimentary Tract.] Z Gastroenterol. 2007;45:971-1001. [PMID: 17874360]

May GR, Sutherland LR, Shaffer EA. Efficacy of bile acid therapy for gallstone dissolution: a meta-analysis of randomized trials. Aliment Pharmacol Ther. 1993;7:139-148. [PMID: 8485266]

Paumgartner G, Pauletzki J, Sackmann M. Ursodeoxycholic acid treatment of cholesterol gallstone disease. Scand J Gastroenterol Suppl. 1994;204:27-31. [PMID: 7824875]

Paumgartner G, Sauter GH. Extracorporeal shock wave lithotripsy of gallstones: 20th anniversary of the first treatment. Eur J Gastroenterol Hepatol. 2005;17:525-527. [PMID: 15827443] Shiffman ML, Kaplan GD, Brinkman-Kaplan V, et al. Prophylaxis against gallstone formation with ursodeoxycholic acid in patients participating in a very-low-calorie diet program. Ann Intern Med. 1995;122:899-905. [PMID: 7755224]

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