Gallstones and gallbladder disease
Description
An in-depth report on the causes, diagnosis, treatment, and prevention of gallstones.
Alternative Names
Cholecystitis; Choledocholithiasis; Bile duct stones
Lithotripsy and Dissolution Therapies
Oral agents used to dissolve gallstones, and lithotripsy alone or in combination with other drugs had gained some popularity in the 1990s. But these oral agents have lost favor with the increase in laparoscopy. They still may have some value in specific circumstances.
Dissolution Therapies
Oral Dissolution Therapy.
Oral dissolution therapy uses bile acids in pill form to dissolve gallstones and may be used in conjunction with lithotripsy, although both techniques are rarely used at present. Ursodiol (ursodeoxycholic acid, Actigall) and chenodiol (Chenix) are the standard oral bile acid drugs used for dissolution. Most doctors prefer ursodeoxycholic acid, which is considered to be among the safest of common drugs and does not seem to have significant side effects. Long-term treatment appears to notably reduce the risk of biliary pain and acute cholecystitis. The treatment is only moderately effective, however, since gallstones recur in the majority of patients.
Patients most likely to benefit from oral dissolution therapy are patients with small stones (less than 1.5 cm in diameter) that have a high cholesterol content.
Patients that probably will
not
benefit from this treatment include obese patients and those that have gallstones that are calcified or composed of bile pigments
Only about 30% of patients, in fact, are candidates for oral dissolution therapy, and the number may be much lower, since compliance is often a problem. The treatment can take up to two years and can cost thousands of dollars per year.
Contact Dissolution Therapy.
Contact dissolution therapy requires the injection of the organic solvent methyl tert-butyl ether (MTBE) into the gallbladder to dissolve gallstones. This is a somewhat technically difficult and hazardous procedure and should be performed only by experienced doctors in hospitals where research on this treatment is being done. Preliminary studies indicate that MTBE rapidly dissolves stones. The ether remains liquid at body temperature and dissolves gallstones within five to twelve hours. Serious side effects include severe burning pain.
Investigative Agents.
Fatty acid bile acid conjugates (FABACs) are experimental agents that are being investigated for dissolving gallstones and also for preventing gallstone formation.
Extracorporeal Shock Wave Lithotripsy
Gallstone fragmentation by extracorporeal shock wave lithotripsy (ESWL) may be an appropriate therapy for some patients who cannot undergo surgery but it is not commonly used anymore. The treatment works best on solitary stones that are less than two centimeters in diameter. Less than 15% of patients are good candidates for lithotripsy. The typical procedure is as follows:
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The patient typically sits in a tub of water.
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High-energy, ultrasound shock waves are directed through the abdominal wall toward the stones.
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The shock waves travel through the soft tissues of the body and break up the stones.
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The stone fragments are then usually small enough to be passed through the bile duct and into the intestines.
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Lithotripsy is generally combined with oral dissolution (bile acid) treatment to help dissolve the fragmented pieces of the original gallstone.
Complications.
Although the mortality rate for lithotripsy is essentially zero, complications include pain in the gallbladder area and pancreatitis, usually occurring within a month of treatment. In addition, not all of the fragments may clear the bile duct. Adding erythromycin to the treatment regimen may help remove these fragments. About 35% of patients who are left with fragments are at risk for further problems, some severe. The chance of recurrence is high with this procedure, and in one study, 45% of patients eventually required surgery. Elderly people may have a lower risk for recurrence than younger adults, which may make this a good choice for some.
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Review Date: 6/12/2006
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Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital
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