Current options in gallstone management. What to do when symptoms are mild or absent.

Recent advances in our understanding of the natural history of gallstones and the introduction of new treatment options have dramatically altered the approach to gallstone management. Most patients with cholelithiasis are asymptomatic, and for them, expectant management is now recommended by many authorities. This approach may also be acceptable for some patients who have only occasional episodes of biliary colic. Laparoscopic cholecystectomy is preferred for patients who have had repeated episodes of biliary colic or acute cholecystitis and who are suitable operative candidates. Nonsurgical options include oral dissolution therapy with bile acids, extracorporeal shock wave lithotripsy, and contact dissolution with methyl tert-butyl ether. Each has significant limitations but may be considered for selected patients with symptomatic gallstones who are not candidates for general anesthesia or who refuse surgery. Future improvements in nonsurgical therapies may ultimately expand their use.