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Treatment of Gallstones

David F. Ransohoff, MD; and William A. Gracie, MD
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From the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, and the University of Michigan, Ann Arbor, Michigan. Requests for Reprints: David F. Ransohoff, MD, CB# 7105, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7105.

Copyright 2004 by the American College of Physicians

Ann Intern Med. 1993;119(7_Part_1):606-619. doi:10.7326/0003-4819-119-7_Part_1-199310010-00010
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Purpose: To critically review the risks and benefits of therapy for asymptomatic and symptomatic persons with gallstones who are considering therapy to prevent future episodes of biliary pain or complications including acute cholecystitis, pancreatitis, or gallbladder cancer.

Data Sources: Review of English-language literature regarding the natural history of persons with gallstones and the operative mortality rates for open cholecystectomy and laparoscopic cholecystectomy. Mathematical simulation modeling was used to derive estimates of lifetime risks for gallstone-related mortality and for life expectancy, for prophylactic cholecystectomy and expectant management, for men and women of different ages.

Results: For persons with asymptomatic gallstones, natural history is so benign that treatment is generally not recommended. For persons with symptomatic gallstones, (that is, that have caused an episode of biliary pain), the rate for subsequent pain is high so that many persons probably choose cholecystectomy to avoid pain; however, about 30% of persons who have had pain do not have further episodes of pain. The expected loss of life for persons with symptomatic stones managed expectantly is roughly several months, on average, and may not be considered high enough in itself to warrant therapy. Although laparoscopic cholecystectomy has become popular with patients and physicians, its safety is yet unknown compared with open cholecystectomy.

Conclusion: Prophylactic cholecystectomy should be recommended for most persons with symptomatic gallstones unless the person wants to try a period of watchful waiting to see if pain recurs. Nonsurgical therapy may be suitable for persons with high operative risk. For persons with asymptomatic gallstones, watchful waiting is the best course.


Grahic Jump Location
Figure 1.
The model can be represented as a Markov state problem with several states.

For calculations in the simulation model, persons with asymptomatic gallstones could have transitions marked A; persons with symptomatic gallstones could have transitions marked S. For details, see text.

Grahic Jump Location




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