Gallstone disease medical therapy
|
Gallstone disease Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Surgery |
|
Case Studies |
|
Gallstone disease medical therapy On the Web |
|
American Roentgen Ray Society Images of Gallstone disease medical therapy |
|
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 and with lithotripsy. However, the mainstay of treatment for gallstone disease is surgically, especially since the introduction of laparoscopic cholecystectomy.
Medical therapy
- Cholesterol gallstones can sometimes be dissolved by oral ursodeoxycholic acid.Gallstones may recur however, once the drug is stopped. 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.[1][2]
- Oral dissolution therapy:
- Drugs made from bile acid are used to dissolve gallstones.
- 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.[3][4][5]
- 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.[6][7]
- Contact dissolution therapy:
- This experimental procedure involves injecting a drug directly into the gallbladder to dissolve cholesterol stones.
- 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.[8][9][10]
Other medical therapies
- Statins - HMG CoA reductase inhibitors will reduce cholesterol secretion hence the rationale for their use.[11][12]
- Ezetimibe — Ezetimibe is a hypocholesterolemic drug that acts by inhibiting intestinal cholesterol absorption.[13]
- Monoterpenes — Rowachol, an orally administered mixture of cyclic monoterpenes is capable of dissolving radiolucent and some radio-opaque gallstones. It also enhances the efficacy of ursodeoxycholic acid or lithotripsy when used in combination.[14][15]
Mechanical nonsurgical gallstone management
Occasionally, extracorporeal shock wave lithotripsy can be used to fracture the stones into small pieces and sand to increase the surface area that is exposed to the bile acids, facilitating dissolution and clearance of the stones.
- Percutaneous cholecystostomy and gallstone extraction - This is a technique used with mostly nonsurgical candidates. The procedure is performed by creating a track to the outside of the body, under fluoroscopic guidance the track is dilated using graded percutaneous dilators. Stones are then extracted and any debris left behind is irrigated to the outside using saline.[16][17]
- Endoscopic placement of a cystic duct stent - During endoscopic retrograde cholangiopancreatography (ERCP) in patients with gallstone-related disease (such as biliary colic, acute cholecystitis, acalculous cholecystitis, and gallstone pancreatitis) and serious comorbidities, a stent is sometimes placed to provide some relief.[18][19][20][21]
- Extracorporeal shock wave lithotripsy (ESWL) — Shock waves generated outside the body are focused on the gallstones to reduce them to sand. This sand is expected to enter the duodenum or to be more dissolvable with oral bile acids. ESWL has been very successful with renal stones, however with gallbladder stones it has a limited use since only a select few patients are candidates for ESWL, some cases reported biliary attacks after the procedure. ESWL is also expensive and has low efficacy in treating gallstones even when in combination with oral bile acids. [22][23][24]
Treatment of biliary colic
These attacks are intensely painful, similar to that of a kidney stone attack. Pain management is an important part of treating biliary colic. Treatment is often with NSAIDs such as ketorolac (Toradol) and diclofenac (Voltaren). Hyoscine butylbromide (Buscopan) is occasionally used but is less effective than analgesics.[25][26][27][28]
Contraindicated medications
Gallstone is considered an absolute contraindication to the use of the following medications:
They increase the cholesterol secretion in the bile.
References
- ↑ Darzi A, Geraghty JG, Williams NN, Sheehan SS, Tanner AN, Keane FB (1994). "The pros and cons of laparoscopic cholecystectomy and extracorporeal shock wave lithotripsy in the management of gallstone disease". Ann R Coll Surg Engl. 76 (1): 42–6. PMC 2502162. PMID 8054014.
- ↑ Portincasa P, van de Meeberg P, van Erpecum KJ, Palasciano G, VanBerge-Henegouwen GP (1997). "An update on the pathogenesis and treatment of cholesterol gallstones". Scand. J. Gastroenterol. Suppl. 223: 60–9. PMID 9200309.
- ↑ Rubin RA, Kowalski TE, Khandelwal M, Malet PF (1994). "Ursodiol for hepatobiliary disorders". Ann. Intern. Med. 121 (3): 207–18. PMID 8017748.
- ↑ Guarino MP, Cong P, Cicala M, Alloni R, Carotti S, Behar J (2007). "Ursodeoxycholic acid improves muscle contractility and inflammation in symptomatic gallbladders with cholesterol gallstones". Gut. 56 (6): 815–20. doi:10.1136/gut.2006.109934. PMC 1954869. PMID 17185355.
- ↑ Hardison WG, Grundy SM (1984). "Effect of ursodeoxycholate and its taurine conjugate on bile acid synthesis and cholesterol absorption". Gastroenterology. 87 (1): 130–5. PMID 6724255.
- ↑ Uchida K, Akiyoshi T, Igimi H, Takase H, Nomura Y, Ishihara S (1991). "Differential effects of ursodeoxycholic acid and ursocholic acid on the formation of biliary cholesterol crystals in mice". Lipids. 26 (7): 526–30. PMID 1943496.
- ↑ van de Heijning BJ, van de Meeberg PC, Portincasa P, Doornewaard H, Hoebers FJ, van Erpecum KJ, Vanberge-Henegouwen GP (1999). "Effects of ursodeoxycholic acid therapy on in vitro gallbladder contractility in patients with cholesterol gallstones". Dig. Dis. Sci. 44 (1): 190–6. PMID 9952243.
- ↑ Ward A, Brogden RN, Heel RC, Speight TM, Avery GS (1984). "Ursodeoxycholic acid: a review of its pharmacological properties and therapeutic efficacy". Drugs. 27 (2): 95–131. PMID 6365507.
- ↑ Bachrach WH, Hofmann AF (1982). "Ursodeoxycholic acid in the treatment of cholesterol cholelithiasis. part I". Dig. Dis. Sci. 27 (8): 737–61. PMID 7094795.
- ↑ Bachrach WH, Hofmann AF (1982). "Ursodeoxycholic acid in the treatment of cholesterol cholelithiasis. Part II". Dig. Dis. Sci. 27 (9): 833–56. PMID 7049627.
- ↑ Saunders KD, Cates JA, Abedin MZ, Roslyn JJ (1993). "Lovastatin and gallstone dissolution: a preliminary study". Surgery. 113 (1): 28–35. PMID 8417484.
- ↑ Chapman BA, Burt MJ, Chisholm RJ, Allan RB, Yeo KH, Ross AG (1998). "Dissolution of gallstones with simvastatin, an HMG CoA reductase inhibitor". Dig. Dis. Sci. 43 (2): 349–53. PMID 9512129.
- ↑ de Bari O, Wang HH, Portincasa P, Paik CN, Liu M, Wang DQ (2014). "Ezetimibe prevents the formation of oestrogen-induced cholesterol gallstones in mice". Eur. J. Clin. Invest. 44 (12): 1159–68. doi:10.1111/eci.12350. PMC 4659711. PMID 25303682.
- ↑ Doran J, Keighley MR, Bell GD (1979). "Rowachol--a possible treatment for cholesterol gallstones". Gut. 20 (4): 312–7. PMC 1412390. PMID 447112.
- ↑ Ellis WR, Somerville KW, Whitten BH, Bell GD (1984). "Pilot study of combination treatment for gall stones with medium dose chenodeoxycholic acid and a terpene preparation". Br Med J (Clin Res Ed). 289 (6438): 153–6. PMC 1442019. PMID 6430390.
- ↑ Davis CA, Landercasper J, Gundersen LH, Lambert PJ (1999). "Effective use of percutaneous cholecystostomy in high-risk surgical patients: techniques, tube management, and results". Arch Surg. 134 (7): 727–31, discussion 731–2. PMID 10401823.
- ↑ Burhenne HJ, Stoller JL (1985). "Minicholecystostomy and radiologic stone extraction in high-risk cholelithiasis patients. Preliminary experience". Am. J. Surg. 149 (5): 632–5. PMID 3993844.
- ↑ Conway JD, Russo MW, Shrestha R (2005). "Endoscopic stent insertion into the gallbladder for symptomatic gallbladder disease in patients with end-stage liver disease". Gastrointest. Endosc. 61 (1): 32–6. PMID 15672053.
- ↑ Shrestha R, Trouillot TE, Everson GT (1999). "Endoscopic stenting of the gallbladder for symptomatic gallbladder disease in patients with end-stage liver disease awaiting orthotopic liver transplantation". Liver Transpl Surg. 5 (4): 275–81. doi:10.1002/lt.500050402. PMID 10388500.
- ↑ Shrestha R, Bilir BM, Everson GT, Steinberg SE (1996). "Endoscopic stenting of gallbladder for symptomatic cholelithiasis in patients with end-stage liver disease awaiting orthotopic liver transplantation". Am. J. Gastroenterol. 91 (3): 595–8. PMID 8633518.
- ↑ Kalloo AN, Thuluvath PJ, Pasricha PJ (1994). "Treatment of high-risk patients with symptomatic cholelithiasis by endoscopic gallbladder stenting". Gastrointest. Endosc. 40 (5): 608–10. PMID 7988828.
- ↑ Pereira SP, Veysey MJ, Kennedy C, Hussaini SH, Murphy GM, Dowling RH (1997). "Gallstone dissolution with oral bile acid therapy. Importance of pretreatment CT scanning and reasons for nonresponse". Dig. Dis. Sci. 42 (8): 1775–82. PMID 9286247.
- ↑ Sackmann M, Delius M, Sauerbruch T, Holl J, Weber W, Ippisch E, Hagelauer U, Wess O, Hepp W, Brendel W (1988). "Shock-wave lithotripsy of gallbladder stones. The first 175 patients". N. Engl. J. Med. 318 (7): 393–7. doi:10.1056/NEJM198802183180701. PMID 3340116.
- ↑ Nicholl JP, Ross B, Milner PC, Brazier JE, Westlake L, Kohler B, Frost E, Williams BT, Johnson AG (1994). "Cost effectiveness of adjuvant bile salt treatment in extracorporeal shock wave lithotripsy for the treatment of gall bladder stones". Gut. 35 (9): 1294–300. PMC 1375711. PMID 7959241.
- ↑ "BestBets: Buscopan (hyoscine butylbromide) in biliary colic".
- ↑ Colli A, Conte D, Valle SD, Sciola V, Fraquelli M (2012). "Meta-analysis: nonsteroidal anti-inflammatory drugs in biliary colic". Aliment. Pharmacol. Ther. 35 (12): 1370–8. doi:10.1111/j.1365-2036.2012.05115.x. PMID 22540869.
- ↑ Henderson SO, Swadron S, Newton E (2002). "Comparison of intravenous ketorolac and meperidine in the treatment of biliary colic". J Emerg Med. 23 (3): 237–41. PMID 12426013.
- ↑ Akriviadis EA, Hatzigavriel M, Kapnias D, Kirimlidis J, Markantas A, Garyfallos A (1997). "Treatment of biliary colic with diclofenac: a randomized, double-blind, placebo-controlled study". Gastroenterology. 113 (1): 225–31. PMID 9207282.