Gallstone Disease: Initial Management

• Cholelithiasis = gallstone
• Choledocholithiasis = presence of gallstones within the common bile duct

Managing gallbladder stones

• Reassure people with asymptomatic gallbladder stones found in a normal gallbladder and normal biliary tree that they do not need treatment unless they develop symptoms.
• Offer laparoscopic cholecystectomy to people diagnosed with symptomatic gallbladder stones.
• Offer early laparoscopic cholecystectomy (to be carried out within 1 week of diagnosis) to people with acute cholecystitis.
• Offer percutaneous cholecystostomy to manage gallbladder empyema when:

• surgery is contraindicated at presentation and
• conservative management is unsuccessful.

• Reconsider laparoscopic cholecystectomy for people who have had percutaneous cholecystostomy once they are well enough for surgery.

Managing common bile duct stones

• Offer bile duct clearance and laparoscopic cholecystectomy to people with symptomatic or asymptomatic common bile duct stones.
• Clear the bile duct:

• surgically at the time of laparoscopic cholecystectomy or
• with endoscopic retrograde cholangiopancreatography (ERCP) before or at the time of laparoscopic cholecystectomy.

• If the bile duct cannot be cleared with ERCP, use biliary stenting to achieve biliary drainage only as a temporary measure until definitive endoscopic or surgical clearance.
• Use the lowest‑cost option suitable for the clinical situation when choosing between day‑case and inpatient procedures for elective ERCP.

Bile Salt Therapy (ursodeoxycholic acid)

• Suppress hepatic cholesterol secretion and inhibit intestinal absorption of cholesterol. It solubilizes cholesterol in micelles and acts by dispersing cholesterol in aqueous media
• Medical management is more effective in patients with good gallbladder function who have small stones (< 1 cm) with a high cholesterol content. 
• Bile salt therapy may be required for more than 6 months and has a success rate less than 50%.

Patient, family member and carer information

• Advise people to avoid food and drink that triggers their symptoms until they have their gallbladder or gallstones removed.
• Advise people that they should not need to avoid food and drink that triggered their symptoms after they have their gallbladder or gallstones removed.

References: 

1. https://www.nice.org.uk/guidance/cg188/chapter/1-Recommendations
2. http://emedicine.medscape.com/article/175667-treatment#d11