Gallstone disease medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
Patients with [[asymptomatic]] gallstones are usually not treated since the chances of [[Complication (medicine)|complications]] developing in the future are low, however, patients with symptomatic gallstones can be treated medically, for example, with [[Ursodiol|ursodeoxycholic acid]]. However, the mainstay of treatment for gallstone disease is surgically, especially since the introduction of [[Laparoscopic surgery|laparoscopic]] [[cholecystectomy]]. Fibrates, including | Patients with [[asymptomatic]] gallstones are usually not treated since the chances of [[Complication (medicine)|complications]] developing in the future are low, however, patients with symptomatic gallstones can be treated medically, for example, with [[Ursodiol|ursodeoxycholic acid]]. However, the mainstay of treatment for gallstone disease is surgically, especially since the introduction of [[Laparoscopic surgery|laparoscopic]] [[cholecystectomy]]. [[Fibrates]], including [[gemfibrozil]] and [[fenofibrates]] are an absolute contraindication in gallstone disease. | ||
==Medical therapy== | ==Medical therapy== | ||
*Pharmacologic medical therapies for gallstone disease include either medical dissolution therapy or contact dissolution therapy.<ref name="pmid8054014">{{cite journal |vauthors=Darzi A, Geraghty JG, Williams NN, Sheehan SS, Tanner AN, Keane FB |title=The pros and cons of laparoscopic cholecystectomy and extracorporeal shock wave lithotripsy in the management of gallstone disease |journal=Ann R Coll Surg Engl |volume=76 |issue=1 |pages=42–6 |year=1994 |pmid=8054014 |pmc=2502162 |doi= |url=}}</ref><ref name="pmid9200309">{{cite journal |vauthors=Portincasa P, van de Meeberg P, van Erpecum KJ, Palasciano G, VanBerge-Henegouwen GP |title=An update on the pathogenesis and treatment of cholesterol gallstones |journal=Scand. J. Gastroenterol. Suppl. |volume=223 |issue= |pages=60–9 |year=1997 |pmid=9200309 |doi= |url=}}</ref> | |||
*[[Pharmacological|Pharmacologic]] medical therapies for gallstone disease include either medical dissolution therapy or contact dissolution therapy.<ref name="pmid8054014">{{cite journal |vauthors=Darzi A, Geraghty JG, Williams NN, Sheehan SS, Tanner AN, Keane FB |title=The pros and cons of laparoscopic cholecystectomy and extracorporeal shock wave lithotripsy in the management of gallstone disease |journal=Ann R Coll Surg Engl |volume=76 |issue=1 |pages=42–6 |year=1994 |pmid=8054014 |pmc=2502162 |doi= |url=}}</ref><ref name="pmid9200309">{{cite journal |vauthors=Portincasa P, van de Meeberg P, van Erpecum KJ, Palasciano G, VanBerge-Henegouwen GP |title=An update on the pathogenesis and treatment of cholesterol gallstones |journal=Scand. J. Gastroenterol. Suppl. |volume=223 |issue= |pages=60–9 |year=1997 |pmid=9200309 |doi= |url=}}</ref> | |||
*[[Cholesterol]] gallstones can sometimes be dissolved by oral [[ursodeoxycholic acid]]. | *[[Cholesterol]] gallstones can sometimes be dissolved by oral [[ursodeoxycholic acid]]. | ||
*Nonsurgical approaches are used only in special situations such as when a patient has a serious medical condition preventing surgery and only then for cholesterol stones. | *Nonsurgical approaches are used only in special situations such as when a patient has a serious medical condition preventing surgery and only then for [[cholesterol]] stones. | ||
*Stones commonly recur within 5 years in patients treated non-surgically. | *Stones commonly recur within 5 years in patients treated non-surgically. | ||
**'''Oral dissolution therapy''': | **'''Oral dissolution therapy''': | ||
***Drugs made from bile acid are used to dissolve gallstones.<ref name="pmid8017748">{{cite journal |vauthors=Rubin RA, Kowalski TE, Khandelwal M, Malet PF |title=Ursodiol for hepatobiliary disorders |journal=Ann. Intern. Med. |volume=121 |issue=3 |pages=207–18 |year=1994 |pmid=8017748 |doi= |url=}}</ref><ref name="pmid17185355">{{cite journal |vauthors=Guarino MP, Cong P, Cicala M, Alloni R, Carotti S, Behar J |title=Ursodeoxycholic acid improves muscle contractility and inflammation in symptomatic gallbladders with cholesterol gallstones |journal=Gut |volume=56 |issue=6 |pages=815–20 |year=2007 |pmid=17185355 |pmc=1954869 |doi=10.1136/gut.2006.109934 |url=}}</ref><ref name="pmid6724255">{{cite journal |vauthors=Hardison WG, Grundy SM |title=Effect of ursodeoxycholate and its taurine conjugate on bile acid synthesis and cholesterol absorption |journal=Gastroenterology |volume=87 |issue=1 |pages=130–5 |year=1984 |pmid=6724255 |doi= |url=}}</ref><ref name="pmid1943496">{{cite journal |vauthors=Uchida K, Akiyoshi T, Igimi H, Takase H, Nomura Y, Ishihara S |title=Differential effects of ursodeoxycholic acid and ursocholic acid on the formation of biliary cholesterol crystals in mice |journal=Lipids |volume=26 |issue=7 |pages=526–30 |year=1991 |pmid=1943496 |doi= |url=}}</ref><ref name="pmid9952243">{{cite journal |vauthors=van de Heijning BJ, van de Meeberg PC, Portincasa P, Doornewaard H, Hoebers FJ, van Erpecum KJ, Vanberge-Henegouwen GP |title=Effects of ursodeoxycholic acid therapy on in vitro gallbladder contractility in patients with cholesterol gallstones |journal=Dig. Dis. Sci. |volume=44 |issue=1 |pages=190–6 |year=1999 |pmid=9952243 |doi= |url=}}</ref> | ***Drugs made from [[bile acid]] are used to dissolve gallstones.<ref name="pmid8017748">{{cite journal |vauthors=Rubin RA, Kowalski TE, Khandelwal M, Malet PF |title=Ursodiol for hepatobiliary disorders |journal=Ann. Intern. Med. |volume=121 |issue=3 |pages=207–18 |year=1994 |pmid=8017748 |doi= |url=}}</ref><ref name="pmid17185355">{{cite journal |vauthors=Guarino MP, Cong P, Cicala M, Alloni R, Carotti S, Behar J |title=Ursodeoxycholic acid improves muscle contractility and inflammation in symptomatic gallbladders with cholesterol gallstones |journal=Gut |volume=56 |issue=6 |pages=815–20 |year=2007 |pmid=17185355 |pmc=1954869 |doi=10.1136/gut.2006.109934 |url=}}</ref><ref name="pmid6724255">{{cite journal |vauthors=Hardison WG, Grundy SM |title=Effect of ursodeoxycholate and its taurine conjugate on bile acid synthesis and cholesterol absorption |journal=Gastroenterology |volume=87 |issue=1 |pages=130–5 |year=1984 |pmid=6724255 |doi= |url=}}</ref><ref name="pmid1943496">{{cite journal |vauthors=Uchida K, Akiyoshi T, Igimi H, Takase H, Nomura Y, Ishihara S |title=Differential effects of ursodeoxycholic acid and ursocholic acid on the formation of biliary cholesterol crystals in mice |journal=Lipids |volume=26 |issue=7 |pages=526–30 |year=1991 |pmid=1943496 |doi= |url=}}</ref><ref name="pmid9952243">{{cite journal |vauthors=van de Heijning BJ, van de Meeberg PC, Portincasa P, Doornewaard H, Hoebers FJ, van Erpecum KJ, Vanberge-Henegouwen GP |title=Effects of ursodeoxycholic acid therapy on in vitro gallbladder contractility in patients with cholesterol gallstones |journal=Dig. Dis. Sci. |volume=44 |issue=1 |pages=190–6 |year=1999 |pmid=9952243 |doi= |url=}}</ref> | ||
***The drugs [[Ursodiol|ursodeoxycholic acid]] (Actigall) and [[chenodeoxycholic acid]] (Chenix) are taken orally and work best for small cholesterol stones. | ***The drugs [[Ursodiol|ursodeoxycholic acid]] (Actigall) and [[chenodeoxycholic acid]] (Chenix) are taken orally and work best for small [[cholesterol]] stones. | ||
***Bile acids work by reducing biliary cholesterol secretion, increasing [[bile acid]] concentration, and therefore, reducing the cholesterol [[saturation]] in bile. | ***[[Bile acid|Bile acids]] work by reducing [[biliary]] [[cholesterol]] secretion, increasing [[bile acid]] concentration, and therefore, reducing the cholesterol [[saturation]] in [[bile]]. | ||
***Months or years of treatment may be necessary before all the stones dissolve. | ***Months or years of treatment may be necessary before all the stones dissolve. | ||
***Both drugs may cause mild [[diarrhea]], and [[chenodeoxycholic acid]] may temporarily raise levels of blood cholesterol and the liver enzyme [[transaminase]]. | ***Both drugs may cause mild [[diarrhea]], and [[chenodeoxycholic acid]] may temporarily raise levels of [[blood]] [[cholesterol]] and the [[liver enzyme]] [[transaminase]]. | ||
**'''Contact dissolution therapy''': | **'''Contact dissolution therapy''': | ||
***This experimental procedure involves injecting a drug directly into the gallbladder to dissolve cholesterol stones.<ref name="pmid6365507">{{cite journal |vauthors=Ward A, Brogden RN, Heel RC, Speight TM, Avery GS |title=Ursodeoxycholic acid: a review of its pharmacological properties and therapeutic efficacy |journal=Drugs |volume=27 |issue=2 |pages=95–131 |year=1984 |pmid=6365507 |doi= |url=}}</ref><ref name="pmid7094795">{{cite journal |vauthors=Bachrach WH, Hofmann AF |title=Ursodeoxycholic acid in the treatment of cholesterol cholelithiasis. part I |journal=Dig. Dis. Sci. |volume=27 |issue=8 |pages=737–61 |year=1982 |pmid=7094795 |doi= |url=}}</ref><ref name="pmid7049627">{{cite journal |vauthors=Bachrach WH, Hofmann AF |title=Ursodeoxycholic acid in the treatment of cholesterol cholelithiasis. Part II |journal=Dig. Dis. Sci. |volume=27 |issue=9 |pages=833–56 |year=1982 |pmid=7049627 |doi= |url=}}</ref> | ***This experimental procedure involves injecting a [[drug]] directly into the gallbladder to dissolve [[cholesterol]] stones.<ref name="pmid6365507">{{cite journal |vauthors=Ward A, Brogden RN, Heel RC, Speight TM, Avery GS |title=Ursodeoxycholic acid: a review of its pharmacological properties and therapeutic efficacy |journal=Drugs |volume=27 |issue=2 |pages=95–131 |year=1984 |pmid=6365507 |doi= |url=}}</ref><ref name="pmid7094795">{{cite journal |vauthors=Bachrach WH, Hofmann AF |title=Ursodeoxycholic acid in the treatment of cholesterol cholelithiasis. part I |journal=Dig. Dis. Sci. |volume=27 |issue=8 |pages=737–61 |year=1982 |pmid=7094795 |doi= |url=}}</ref><ref name="pmid7049627">{{cite journal |vauthors=Bachrach WH, Hofmann AF |title=Ursodeoxycholic acid in the treatment of cholesterol cholelithiasis. Part II |journal=Dig. Dis. Sci. |volume=27 |issue=9 |pages=833–56 |year=1982 |pmid=7049627 |doi= |url=}}</ref> | ||
***The drug, methylterbutyl ether, can dissolve some stones in 1 to 3 days, but it causes irritation and some complications have been reported. | ***The drug, methylterbutyl ether, can dissolve some stones in 1 to 3 days, but it causes irritation and some complications have been reported. | ||
***The procedure is being tested in symptomatic patients with small stones. | ***The procedure is being tested in symptomatic patients with small stones. | ||
===Dosing=== | ===Dosing=== | ||
* '''1 Gallstone disease''' | |||
** 1.1 '''Biliary tract''' | *'''1 Gallstone disease''' | ||
*** 1.1.1 | **1.1 '''Biliary tract''' | ||
**** 1.1.1.1 Gall stone dissolution | ***'''1.1.1 Adult''' | ||
***** Preferred regimen (1): [[Ursodiol]] PO 8-10 mg/kg q24h in 2-3 divided doses (Max up to 24 months) | ****'''1.1.1.1 Gall stone dissolution''' | ||
**** 1.1.1.2 Gall stone prevention | *****Preferred regimen (1): [[Ursodiol]] PO 8-10 mg/kg q24h in 2-3 divided doses (Max up to 24 months) | ||
***** Preferred regimen (1): [[Ursodiol]] PO 300 mg q12h | ****'''1.1.1.2 Gall stone prevention''' | ||
**** Primary biliary cirrhosis | *****Preferred regimen (1): [[Ursodiol]] PO 300 mg q12h | ||
***** Preferred regimen (3): ([[Urso]], [[Urso forte]]): Oral: 13-15 mg/kg/day in 2-4 divided doses (with food) | ****'''Primary biliary cirrhosis''' | ||
*** 1.1.2 | *****Preferred regimen (3): ([[Urso]], [[Urso forte]]): Oral: 13-15 mg/kg/day in 2-4 divided doses (with food) | ||
**** 1.1.2.1 | ***'''1.1.2 Pediatric''' | ||
***** Preferred regimen (1):In parenteral nutrition-induced cholestasis in neonates, some experts recommend: Oral: 30 mg/kg/day in 2- 3 divided doses | ****'''1.1.2.1 Children < 8 years of age''' | ||
**** 1.1.2.2 | *****Preferred regimen (1):In parenteral nutrition-induced cholestasis in neonates, some experts recommend: Oral: 30 mg/kg/day in 2- 3 divided doses | ||
**** 1.1.2.2.1 Gall stone dissolution | ****'''1.1.2.2 Children > 8 years of age''' | ||
***** Preferred regimen (1): [[Ursodiol]] PO 25 mg/kg q24h (Max up to 13 months) | ****'''1.1.2.2.1 Gall stone dissolution''' | ||
* '''2 Other medical therapies'''<ref name="pmid8417484">{{cite journal |vauthors=Saunders KD, Cates JA, Abedin MZ, Roslyn JJ |title=Lovastatin and gallstone dissolution: a preliminary study |journal=Surgery |volume=113 |issue=1 |pages=28–35 |year=1993 |pmid=8417484 |doi= |url=}}</ref><ref name="pmid9512129">{{cite journal |vauthors=Chapman BA, Burt MJ, Chisholm RJ, Allan RB, Yeo KH, Ross AG |title=Dissolution of gallstones with simvastatin, an HMG CoA reductase inhibitor |journal=Dig. Dis. Sci. |volume=43 |issue=2 |pages=349–53 |year=1998 |pmid=9512129 |doi= |url=}}</ref><ref name="pmid25303682">{{cite journal |vauthors=de Bari O, Wang HH, Portincasa P, Paik CN, Liu M, Wang DQ |title=Ezetimibe prevents the formation of oestrogen-induced cholesterol gallstones in mice |journal=Eur. J. Clin. Invest. |volume=44 |issue=12 |pages=1159–68 |year=2014 |pmid=25303682 |pmc=4659711 |doi=10.1111/eci.12350 |url=}}</ref><ref name="pmid447112">{{cite journal |vauthors=Doran J, Keighley MR, Bell GD |title=Rowachol--a possible treatment for cholesterol gallstones |journal=Gut |volume=20 |issue=4 |pages=312–7 |year=1979 |pmid=447112 |pmc=1412390 |doi= |url=}}</ref><ref name="pmid6430390">{{cite journal |vauthors=Ellis WR, Somerville KW, Whitten BH, Bell GD |title=Pilot study of combination treatment for gall stones with medium dose chenodeoxycholic acid and a terpene preparation |journal=Br Med J (Clin Res Ed) |volume=289 |issue=6438 |pages=153–6 |year=1984 |pmid=6430390 |pmc=1442019 |doi= |url=}}</ref> | *****Preferred regimen (1): [[Ursodiol]] PO 25 mg/kg q24h (Max up to 13 months) | ||
*'''2 Other medical therapies'''<ref name="pmid8417484">{{cite journal |vauthors=Saunders KD, Cates JA, Abedin MZ, Roslyn JJ |title=Lovastatin and gallstone dissolution: a preliminary study |journal=Surgery |volume=113 |issue=1 |pages=28–35 |year=1993 |pmid=8417484 |doi= |url=}}</ref><ref name="pmid9512129">{{cite journal |vauthors=Chapman BA, Burt MJ, Chisholm RJ, Allan RB, Yeo KH, Ross AG |title=Dissolution of gallstones with simvastatin, an HMG CoA reductase inhibitor |journal=Dig. Dis. Sci. |volume=43 |issue=2 |pages=349–53 |year=1998 |pmid=9512129 |doi= |url=}}</ref><ref name="pmid25303682">{{cite journal |vauthors=de Bari O, Wang HH, Portincasa P, Paik CN, Liu M, Wang DQ |title=Ezetimibe prevents the formation of oestrogen-induced cholesterol gallstones in mice |journal=Eur. J. Clin. Invest. |volume=44 |issue=12 |pages=1159–68 |year=2014 |pmid=25303682 |pmc=4659711 |doi=10.1111/eci.12350 |url=}}</ref><ref name="pmid447112">{{cite journal |vauthors=Doran J, Keighley MR, Bell GD |title=Rowachol--a possible treatment for cholesterol gallstones |journal=Gut |volume=20 |issue=4 |pages=312–7 |year=1979 |pmid=447112 |pmc=1412390 |doi= |url=}}</ref><ref name="pmid6430390">{{cite journal |vauthors=Ellis WR, Somerville KW, Whitten BH, Bell GD |title=Pilot study of combination treatment for gall stones with medium dose chenodeoxycholic acid and a terpene preparation |journal=Br Med J (Clin Res Ed) |volume=289 |issue=6438 |pages=153–6 |year=1984 |pmid=6430390 |pmc=1442019 |doi= |url=}}</ref> | |||
**'''2.1 Lipid lowering agents''' | **'''2.1 Lipid lowering agents''' | ||
*** 2.1.1 [[HMG-CoA reductase|HMG CoA reductase]] inhibitors | ***'''2.1.1 [[HMG-CoA reductase|HMG CoA reductase]] inhibitors''' | ||
****Preferred regimen (1): [[Statins]] | ****Preferred regimen (1): [[Statins]] | ||
***:'''NOTE (1):''' [[Statins]]will reduce cholesterol secretion hence the rationale for their use. | ***:'''NOTE (1):''' [[Statins]]will reduce cholesterol secretion hence the rationale for their use. | ||
***2.1.2 Cholesterol absorption inhibitor | ***2.1.2 '''Cholesterol absorption inhibitor''' | ||
****Preferred regimen (1): '''[[Ezetimibe]]''' | ****Preferred regimen (1): '''[[Ezetimibe]]''' | ||
***:'''NOTE (1):''' Ezetimibe is a hypocholesterolemic drug that acts by inhibiting intestinal cholesterol absorption. | ***:'''NOTE (1):''' [[Ezetimibe]] is a hypocholesterolemic drug that acts by inhibiting [[intestinal]] [[cholesterol]] [[absorption]]. | ||
**'''2.2 Dissolution agents''' | **'''2.2 Dissolution agents''' | ||
* | ***2.2.1 [[Monoterpenes]] | ||
*Preferred regimen (1): Rowachol | ****Preferred regimen (1): Rowachol | ||
***:'''NOTE (1):''' Rowachol, an orally administered mixture of cyclic [[monoterpenes]] is capable of dissolving radiolucent and some radio-opaque gallstones. | ***:'''NOTE (1):''' Rowachol, an orally administered mixture of cyclic [[monoterpenes]] is capable of dissolving radiolucent and some radio-opaque gallstones. | ||
***:'''NOTE (2):''' It also enhances the efficacy of [[Ursodiol|ursodeoxycholic acid]] or [[Lithotriptor|lithotripsy]] when used in combination. | ***:'''NOTE (2):''' It also enhances the efficacy of [[Ursodiol|ursodeoxycholic acid]] or [[Lithotriptor|lithotripsy]] when used in combination. | ||
* '''3 Biliary colic treatment'''<ref>{{cite web |url=http://www.bestbets.org/bets/bet.php?id=882 |title=BestBets: Buscopan (hyoscine butylbromide) in biliary colic. |format= |work= |accessdate=}}</ref><ref name="pmid22540869">{{cite journal |vauthors=Colli A, Conte D, Valle SD, Sciola V, Fraquelli M |title=Meta-analysis: nonsteroidal anti-inflammatory drugs in biliary colic |journal=Aliment. Pharmacol. Ther. |volume=35 |issue=12 |pages=1370–8 |year=2012 |pmid=22540869 |doi=10.1111/j.1365-2036.2012.05115.x |url=}}</ref><ref name="pmid12426013">{{cite journal |vauthors=Henderson SO, Swadron S, Newton E |title=Comparison of intravenous ketorolac and meperidine in the treatment of biliary colic |journal=J Emerg Med |volume=23 |issue=3 |pages=237–41 |year=2002 |pmid=12426013 |doi= |url=}}</ref><ref name="pmid9207282">{{cite journal |vauthors=Akriviadis EA, Hatzigavriel M, Kapnias D, Kirimlidis J, Markantas A, Garyfallos A |title=Treatment of biliary colic with diclofenac: a randomized, double-blind, placebo-controlled study |journal=Gastroenterology |volume=113 |issue=1 |pages=225–31 |year=1997 |pmid=9207282 |doi= |url=}}</ref> | *'''3 Biliary colic treatment'''<ref>{{cite web |url=http://www.bestbets.org/bets/bet.php?id=882 |title=BestBets: Buscopan (hyoscine butylbromide) in biliary colic. |format= |work= |accessdate=}}</ref><ref name="pmid22540869">{{cite journal |vauthors=Colli A, Conte D, Valle SD, Sciola V, Fraquelli M |title=Meta-analysis: nonsteroidal anti-inflammatory drugs in biliary colic |journal=Aliment. Pharmacol. Ther. |volume=35 |issue=12 |pages=1370–8 |year=2012 |pmid=22540869 |doi=10.1111/j.1365-2036.2012.05115.x |url=}}</ref><ref name="pmid12426013">{{cite journal |vauthors=Henderson SO, Swadron S, Newton E |title=Comparison of intravenous ketorolac and meperidine in the treatment of biliary colic |journal=J Emerg Med |volume=23 |issue=3 |pages=237–41 |year=2002 |pmid=12426013 |doi= |url=}}</ref><ref name="pmid9207282">{{cite journal |vauthors=Akriviadis EA, Hatzigavriel M, Kapnias D, Kirimlidis J, Markantas A, Garyfallos A |title=Treatment of biliary colic with diclofenac: a randomized, double-blind, placebo-controlled study |journal=Gastroenterology |volume=113 |issue=1 |pages=225–31 |year=1997 |pmid=9207282 |doi= |url=}}</ref> | ||
**'''3.1 Analgesics''' | **'''3.1 Analgesics''' | ||
*** 3.1.1 Non-steroidal anti-inflammatory drugs | ***'''3.1.1 Non-steroidal anti-inflammatory drugs''' | ||
****Preferred regimen (1): [[Ketorolac]] and [[Diclofenac]] | ****Preferred regimen (1): [[Ketorolac]] and [[Diclofenac]] | ||
***:'''NOTE (1):''' During pregnancy, [[Non-steroidal anti-inflammatory drug|NSAIDs]] are best to be avoided, especially beyond 32 weeks. | ***:'''NOTE (1):''' During [[pregnancy]], [[Non-steroidal anti-inflammatory drug|NSAIDs]] are best to be avoided, especially beyond 32 weeks. | ||
*** 3.1.2 Biliary colic in pregnancy | ***'''3.1.2 Biliary colic in pregnancy''' | ||
****Preferred regimen (1): [[Scopolamine|Hyoscine butylbromide]] | ****Preferred regimen (1): [[Scopolamine|Hyoscine butylbromide]] | ||
****Preferred regimen (2): [[Opioid]] analgesics | ****Preferred regimen (2): [[Opioid]] analgesics | ||
| Line 61: | Line 64: | ||
===Contraindicated medications=== | ===Contraindicated medications=== | ||
*Gallstones are considered an absolute contraindication to the use of the following medications: | *Gallstones are considered an absolute contraindication to the use of the following medications: | ||
**These drugs increase the cholesterol secretion in the bile. | **These drugs increase the [[cholesterol]] secretion in the bile. | ||
***[[Fenofibrate]] | ***[[Fenofibrate]] | ||
***[[Gemfibrozil]] | ***[[Gemfibrozil]] | ||
| Line 68: | Line 72: | ||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
<references /> | |||
[[Category:Needs content]] | [[Category:Needs content]] | ||
| Line 73: | Line 80: | ||
[[Category:Hepatology]] | [[Category:Hepatology]] | ||
[[Category:Surgery]] | [[Category:Surgery]] | ||
Latest revision as of 22:02, 22 December 2020
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Gallstone disease Microchapters |
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Treatment |
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Surgery |
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Gallstone disease medical therapy On the Web |
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American Roentgen Ray Society Images of Gallstone disease medical therapy |
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Risk calculators and risk factors for Gallstone disease medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]
Overview
Patients with asymptomatic gallstones are usually not treated since the chances of complications developing in the future are low, however, patients with symptomatic gallstones can be treated medically, for example, with ursodeoxycholic acid. However, the mainstay of treatment for gallstone disease is surgically, especially since the introduction of laparoscopic cholecystectomy. Fibrates, including gemfibrozil and fenofibrates are an absolute contraindication in gallstone disease.
Medical therapy
- Pharmacologic medical therapies for gallstone disease include either medical dissolution therapy or contact dissolution therapy.[1][2]
- Cholesterol gallstones can sometimes be dissolved by oral ursodeoxycholic acid.
- Nonsurgical approaches are used only in special situations such as when a patient has a serious medical condition preventing surgery and only then for cholesterol stones.
- Stones commonly recur within 5 years in patients treated non-surgically.
- Oral dissolution therapy:
- Drugs made from bile acid are used to dissolve gallstones.[3][4][5][6][7]
- The drugs ursodeoxycholic acid (Actigall) and chenodeoxycholic acid (Chenix) are taken orally and work best for small cholesterol stones.
- Bile acids work by reducing biliary cholesterol secretion, increasing bile acid concentration, and therefore, reducing the cholesterol saturation in bile.
- Months or years of treatment may be necessary before all the stones dissolve.
- Both drugs may cause mild diarrhea, and chenodeoxycholic acid may temporarily raise levels of blood cholesterol and the liver enzyme transaminase.
- Contact dissolution therapy:
- This experimental procedure involves injecting a drug directly into the gallbladder to dissolve cholesterol stones.[8][9][10]
- The drug, methylterbutyl ether, can dissolve some stones in 1 to 3 days, but it causes irritation and some complications have been reported.
- The procedure is being tested in symptomatic patients with small stones.
- Oral dissolution therapy:
Dosing
- 1 Gallstone disease
- 1.1 Biliary tract
- 1.1.1 Adult
- 1.1.1.1 Gall stone dissolution
- Preferred regimen (1): Ursodiol PO 8-10 mg/kg q24h in 2-3 divided doses (Max up to 24 months)
- 1.1.1.2 Gall stone prevention
- Preferred regimen (1): Ursodiol PO 300 mg q12h
- Primary biliary cirrhosis
- Preferred regimen (3): (Urso, Urso forte): Oral: 13-15 mg/kg/day in 2-4 divided doses (with food)
- 1.1.1.1 Gall stone dissolution
- 1.1.2 Pediatric
- 1.1.2.1 Children < 8 years of age
- Preferred regimen (1):In parenteral nutrition-induced cholestasis in neonates, some experts recommend: Oral: 30 mg/kg/day in 2- 3 divided doses
- 1.1.2.2 Children > 8 years of age
- 1.1.2.2.1 Gall stone dissolution
- Preferred regimen (1): Ursodiol PO 25 mg/kg q24h (Max up to 13 months)
- 1.1.2.1 Children < 8 years of age
- 1.1.1 Adult
- 1.1 Biliary tract
- 2 Other medical therapies[11][12][13][14][15]
- 2.1 Lipid lowering agents
- 2.1.1 HMG CoA reductase inhibitors
- Preferred regimen (1): Statins
- NOTE (1): Statinswill reduce cholesterol secretion hence the rationale for their use.
- 2.1.2 Cholesterol absorption inhibitor
- Preferred regimen (1): Ezetimibe
- NOTE (1): Ezetimibe is a hypocholesterolemic drug that acts by inhibiting intestinal cholesterol absorption.
- 2.1.1 HMG CoA reductase inhibitors
- 2.2 Dissolution agents
- 2.2.1 Monoterpenes
- Preferred regimen (1): Rowachol
- NOTE (1): Rowachol, an orally administered mixture of cyclic monoterpenes is capable of dissolving radiolucent and some radio-opaque gallstones.
- NOTE (2): It also enhances the efficacy of ursodeoxycholic acid or lithotripsy when used in combination.
- 2.2.1 Monoterpenes
- 2.1 Lipid lowering agents
- 3 Biliary colic treatment[16][17][18][19]
- 3.1 Analgesics
- 3.1.1 Non-steroidal anti-inflammatory drugs
- Preferred regimen (1): Ketorolac and Diclofenac
- 3.1.2 Biliary colic in pregnancy
- Preferred regimen (1): Hyoscine butylbromide
- Preferred regimen (2): Opioid analgesics
- Preferred regimen (3): Acetaminophen
- 3.1.1 Non-steroidal anti-inflammatory drugs
- 3.1 Analgesics
Contraindicated medications
- Gallstones are considered an absolute contraindication to the use of the following medications:
- These drugs increase the cholesterol secretion in the bile.
References
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- ↑ "BestBets: Buscopan (hyoscine butylbromide) in biliary colic".
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