Guidelines for the Treatment of Gallstones

doi:10.1059/0003-4819-119-7_Part_1-199310010-00011

Guidelines for the Treatment of Gallstones

American College of Physicians*

*These guidelines were authored by David F. Ransohoff, MD; William A. Gracie, MD; John P. Schmittner, and were developed for the Health and Public Policy Committee by the Clinical Efficacy Assessment Subcommittee: Ernest L. Mazzaferri, MD, Chair; John R. Feussner, MD; Edward J. Huth, MD; Gerald R. Kerby, MD; Francis J. Klocke, MD; Albert G. Mulley, Jr., MD; George E. Thibault, MD; Col. Michael J. Kussman, MD. Members of the Health and Public Policy Committee were Clifton R. Cleaveland, MD, Chair; Cecil O. Samuelson, Jr., MD; Christine K. Cassel, MD; David J. Gullen, MD; Ernest L. Mazzaferri, MD; Quentin D. Young, MD; Whitney Addington, MD; Robert A. Berenson, MD; John E. Eisenberg, MD; Nancy E. Gary, MD; P. Preston Reynolds, MD; Gerald E. Thomson, MD; Mack V. Traynor, Jr., MD. The guidelines were approved by the Board of Regents on 29 March 1993. Requests for Reprints: Linda Johnson White, Director, Scientific Policy, American College of Physicians, Independence Mall West, Sixth Street at Race, Philadelphia, PA 19106-1572.

[The square-bracketed numbers are references to the numbered sections in the review article in this issue (Treatment of Gallstone Disease; see pages 606-619), which support statements made here.The Editors.]

Proper decision making for gallstone disease necessitates that clinicians and patients recognize three categories of disease. The first category encompasses silent gallstones (asymptomatic disease). The second category involves disease that causes uncomplicated biliary pain (symptomatic disease). A third category involves complications of gallstone disease, such as acute cholecystitis and gallbladder cancer. The present guideline focuses on the first two categories only.

This categorization of disease allows clinicians and patients to choose the treatment most appropriate to the specific patient. Therapy could be expectant management, a wait-and-see position in which intervention is postponed until a more serious problem develops. Therapy may be nonsurgical, in which only the gallstones, but not the gallbladder, are removed. The last option, the surgical approach, involves the removal of both the gallstones and the gallbladder. To choose the most appropriate option requires information about the efficacy, safety, and benefits of each.

Therapy Choices

Because expectant management delays treatment, this therapy poses a dilemma. Watchful waiting may avoid an unnecessary intervention. However, delaying an intervention is a tradeoff that could result in an adverse consequence by not preventing a future complication or by requiring the intervention when the patient is in an older, frailer state when the associated morbidity and mortality are greater [2.4].

Nonsurgical therapy dissolves gallstones by solubilizing their cholesterol through various methods. This therapy is generally limited to gallstones with a diameter less than 1.5 cm and whose content is primarily cholesterol. Options include oral bile acids that dissolve cholesterol stones by increasing the cholesterol in bile. However, suitable candidates would account for only 20% of cholecystectomy patients. Because bile acids must be taken daily for up …

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