Intended for healthcare professionals

Practice Uncertainties

Can surgery be avoided in patients with symptomatic gallstone disease and no complications?

BMJ 2019; 367 doi: (Published 11 October 2019) Cite this as: BMJ 2019;367:l5709
  1. Miriam Brazzelli, reader on research1,
  2. Alison Avenell, professor1,
  3. Katie Gillies, senior research fellow1,
  4. Craig Ramsay, professor1,
  5. Irfan Ahmed, consultant surgeon1 2
  1. 1Health Service Research Unit, 3rd floor Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZU
  2. 2Department of Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, AB25 2ZN
  1. Correspondence to: M Brazzelli m.brazzelli{at},

What you need to know

  • Laparoscopic cholecystectomy is the current treatment of choice for people with symptoms of gallstone disease

  • There is limited evidence from two randomised controlled trials that conservative management with pain medications and observation may be a safe alternative to surgery in patients with acute cholecystitis or biliary colic and no complications, as symptoms may subside over time and not recur

  • A proportion of patients with uncomplicated gallstone disease who are initially treated conservatively may never require surgery

Cholelithiasis or gallstone disease affects between 5.3% and 25% of people, according to clinical survey reports from Europe, North and South America, and Asia.12345 In most people, gallstones are asymptomatic. About 20% of people with gallstones experience pain and complications.6 Acute cholecystitis describes inflammation of the gall bladder, usually due to obstruction by a gallstone. It causes characteristic severe pain, known as biliary pain, in the right upper abdomen that can last from a few minutes to hours.7 Box 1 lists the complications of gallstone disease. Here, we focus on management of uncomplicated symptomatic gallstone disease.

Box 1

Complications of gallstones which require immediate referral for surgical, radiological, or endoscopic intervention67

  • Perforation or gangrene of the gallbladder

  • Inflammation of the bile ducts (acute cholangitis)

  • Obstructive jaundice due to obstruction of the common bile duct

  • Inflammation of the pancreas (acute pancreatitis)

  • Acute inflammation or infection of the gall bladder (severe acute cholecystitis), which may lead to complications such as empyema (collection of pus in the gallbladder)


Current clinical guidelines in the US and UK recommend laparoscopic cholecystectomy for patients with biliary pain or acute cholecystitis and radiological evidence of gallstones.8910 Surgical treatment carries the risk of complications. Some patients continue to experience symptoms after surgery. Persistent diarrhoea or constipation are often reported …

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