Gallstones - approach to medical management

Between 10% and 15% of individuals in the industrialized world have gallstones. The standard treatment is laparoscopic cholecystectomy, making gallstone disease the second most costly digestive disorder in most Western countries. Despite a rapid convalescence, the procedure is not devoid of morbidity or even mortality. Bile duct injury is particularly troublesome, occurring in 0.1% to 0.5% of cases, even in the most experienced hands. Moreover, some 20% of patients continue to suffer from pain (the main indication for treatment) after cholecystectomy. In patients with mild symptoms, surgical treatment has been associated with a higher morbidity than the natural course of the disease. Medical dissolution therapy with bile acids is an alternative for patients with mild-to-moderate symptoms due to cholesterol gallstones. Chenodeoxycholic acid (CDCA, chenodiol) has been largely replaced by the safer and more efficient ursodeoxycholic acid (UDCA). The main drawbacks of UDCA treatment are its low efficacy (approximately 40%), slowness in action, and the possibility of stone recurrence. However, this treatment is extremely safe, and the efficacy and slowness can be somewhat improved by stricter patient selection. Moreover, patient symptoms may respond to this therapy even without complete stone dissolution. New strategies employing more efficient bile acids or related compounds may increase the efficacy of medical dissolution. Furthermore, recent advances in the understanding of biliary lipid secretion and regulation should offer novel opportunities to further improve the prospects of medical treatment of gallstones.