Editing Gallstone disease (section)

== '''Medical management of cholelithiasis''' ==

* High recurrence rates limit use to patients who cannot have a GA, have stones <1cm with minimal calcification, have mild disease only, have a patent cystic duct, and have good gallbladder mucosal concentration function
* Oral bile salt therapy (ursodeoxycholic acid)
** Can take several years to work, especially with large gallstones
** Dissolves gallstones by solubilising cholesterol from the surface
** A patent cystic duct is required for it to enter the gallbladder
** 10mg/kg/day in two to three divided doses, and up to 15mg/kg/day in patients with gallstones >2cm
** Abdominal USS every 6-12 months - but keep in mind that stones dissolve from the inside out, so they do not seem to get smaller until the outer shell disintegrates all at once
** Stones dissolve at about 1mm/month
** Overall success rate is about 30-50% for stones <2cm, but symptoms seem to reduce within a few weeks of starting treatment
** Recurrence 45% at five years
** Continue UDA for at least six months after USS demonstrates clearance of stones, and can be continued indefinitely in patients who are high risk for recurrent stones and cholecystectomy
* Contact dissolution
* Extracorporeal shock wave lithotripsy
** Recurrence rate 60% at five years - can be used in patients with single stones 0.5-2cm in size
** 30-50% get biliary colic
** Overall not useful
* Gallstone extraction
** Can be done after percutaneous cholecystostomy
** Dilate tract a few weeks after placement
** Use a basket to extract stones and irrigate