المرارة والجراحة

Treating gallstones without surgery: the alternatives, their success rates and their limits

د. تامر الألفي

Can gallstones be treated without an operation? Sometimes observation alone is enough, or a medicine to dissolve certain types of stones may be considered — but there is no single non-surgical alternative that suits everyone. Stones that cause no symptoms are different from stones causing repeated colic, and different again from stones in the bile duct or situations with inflammation or jaundice. Laparoscopic removal of the gallbladder is the usual treatment for stones that cause symptoms, with structured observation possible in selected, uncomplicated cases.

This article is general education, not a prescription or a decision to postpone surgery. Your doctor's and treating team's instructions always come first. The information was checked against the cited sources; this check is not a personal clinical endorsement by Dr. Tamer Elalfy.

First: where is the stone, and is it really the cause of the pain?

The gallbladder stores the bile the liver produces. Stones may sit inside it without any problem, block its outlet and cause colic, or travel into the bile duct and cause blockage, infection or pancreatitis. A stone on ultrasound does not by itself prove that every bloating, heartburn or abdominal pain comes from the gallbladder; that is why the pattern of the pain, the ultrasound and the liver tests are reviewed, and an MRI of the ducts or an endoscopic ultrasound may be needed. [1]

1. Observation without surgery: who does it suit?

Stones without symptoms: NICE advises against treating gallstones found incidentally when the gallbladder and bile ducts are normal, unless symptoms appear. There are special circumstances a doctor will identify, and those exceptions should not be turned into a general recommendation to operate on every silent stone. [1]

Uncomplicated symptoms: some patients can discuss structured observation with their surgeon after complications have been ruled out, with a plan for pain, follow-up and urgent warning signs. This is a shared choice, not simply ignoring the stones. NICE still recommends offering laparoscopic cholecystectomy for stones that cause symptoms. [1]

In the C-GALL randomised trial, which included 434 adults with uncomplicated symptomatic gallstones, there was no difference in the primary measure of bodily pain and general quality of life over 18 months between the observation strategy and the surgery strategy. About 25% of the observation group had an operation during that period — meaning roughly three quarters did not have surgery at that point. But this is not a stone-dissolution rate and not a guarantee of cure or lifelong safety, and some gallbladder-specific symptom measures favoured the surgery group. Nor did every member of the surgery group actually have the operation during follow-up, so the result should not be read as a comparison of a completed operation against no operation in everyone. [2]

These results do not justify postponing treatment of duct blockage, inflammation, pancreatitis or an acute situation needing intervention; the decision to observe changes if attacks become repeated or more severe, or if complications appear.

The five-year follow-up of the SECURE trial, published in JAMA Surgery in 2024, adds that patient selection for surgery matters: it compared a more restrictive strategy for selecting surgery with usual care and did not compare surgery directly against no surgery. Operations were performed in 73.2% versus 81.5%, and freedom from pain was about 61.2% versus 62.8% among those who answered the pain questionnaire; the study did not statistically prove non-inferiority of the restrictive strategy, and pain responses were available for 716 of 1067 participants. These results support discussing the source of the pain and expectations — not a promise that postponing surgery is safe for everyone. [7]

2. Ursodeoxycholic acid: dissolving only some stones

Also called UDCA or ursodiol. It can dissolve some cholesterol-rich, non-calcified stones, especially small ones, in people a doctor selects carefully — for example those who are not suitable for surgery or who decline it after understanding the options. It does not dissolve pigment or calcified stones, and it is not a quick treatment or a suitable alternative in ongoing acute inflammation, duct blockage or cholangitis, or gallstone pancreatitis. [3]

What is the success rate of the medicine?

About 30% complete dissolution: in the medicine's official label data, in patients with non-calcified stones smaller than 20 mm, after treatment that may last up to two years.
81% in a very small stone category, up to 5 mm: a figure observed in the label data for a specific category — not an expected rate for every patient, and not evidence that the medicine is better than surgery. The label does not state the size of that category or a separate follow-up period for it.
Stones may return in up to 50% within five years in those whose stones were successfully dissolved with bile-acid treatment; successful dissolution does not mean the tendency to form new stones has ended.

These numbers come from the medicine's label studies and not from a recent trial comparing all the alternatives, and they cannot be transferred to large or calcified stones. Treatment takes months with imaging follow-up, and the dose or duration cannot be determined from this article. [3]

Why is the medicine not given to everyone? Guidelines separate the possibility of dissolving a stone in a selected patient from the value of using the medicine routinely to improve symptoms and prevent complications. EASL guidance does not recommend dissolving gallbladder stones with bile acids, alone or with lithotripsy, routinely, and the BNF notes that the evidence does not support ursodeoxycholic acid for treating gallstone disease in general. The dissolution figures in the label do not change these limits. [4] [5]

3. Shockwave lithotripsy for gallbladder stones

Breaking gallbladder stones with shockwaves from outside the body, ESWL, is not the usual treatment the way it can be for some kidney stones. It breaks the stone but does not remove the gallbladder or the reason the stones form, and fragments may remain or the stones may return. EASL does not recommend using it routinely with dissolution medicines for gallbladder stones. There is no single modern success rate that can be generalised; historical figures are affected by stone size and number and by patient selection, and breaking a stone does not equal its complete disappearance or the prevention of complications. [4]

4. ERCP: not a general alternative to gallbladder removal

ERCP is used mainly to remove bile duct stones or treat duct blockage, not to remove the usual stones from inside the gallbladder. Specialised fragmentation tools may be used for difficult duct stones, and that is different from breaking gallbladder stones outside the body. NICE recommends clearing the duct and removing the gallbladder in people with duct stones, with the method and timing chosen according to the situation. The plan may be modified when a patient's surgical risk is very high. [1]

Successfully removing a duct stone does not mean the gallbladder stones have been removed, and ERCP carries risks including pancreatitis, bleeding and infection; it is not performed just because stones are present in the gallbladder without a specific reason.

5. Gallbladder drainage: for inflammation in selected high-risk patients

A tube may be used to drain the gallbladder through the skin when a patient's health prevents surgery and conservative treatment fails to control a collection of pus in the gallbladder. The aim is to treat the inflammation and drain it — not to dissolve stones or to offer an optional alternative to every patient. NICE recommends re-evaluating gallbladder removal once the patient's condition allows. A specialist team may discuss endoscopic drainage options in suitable cases; the decision depends on the risks and the available expertise. [1]

6. Food, herbs and the "gallbladder cleanse"

Avoiding foods that trigger your symptoms may reduce attacks, but it does not prove that stones dissolve. There is no need to eliminate fat completely or follow a harsh diet; choose a balanced diet and discuss a suitable plan with your doctor, and avoid rapid, unplanned weight loss. There is no reliable evidence that olive oil and lemon, mixtures and herbs, or a "gallbladder cleanse" remove stones safely. The clumps seen in the stool after these recipes are not evidence that stones came out; they may be products of the mixture itself. These recipes may cause vomiting, diarrhoea or pain and delay the evaluation you need. [6]

How to compare success rates fairly

Ask first: does the number mean the stone dissolved on imaging, or less pain, or avoiding an operation during a defined period, or preventing stones from returning? These are different outcomes. Comparing "81% dissolution for very small stones" with "75% had no operation within 18 months" as if they described the same cure is not valid. Equally, removing the gallbladder does not guarantee that every abdominal pain will disappear, nor does it completely prevent every future bile duct problem; retained stones may exist or duct stones may form, and pain may have another cause. That is why there is no honest general "gallstone treatment success rate" that applies to everyone.

When surgery or urgent intervention matters more

Intervention becomes more important when the colic repeats and affects your life, or when cholecystitis occurs, or the duct becomes blocked or infected, or gallstone-related pancreatitis develops. NICE recommends early surgery for acute cholecystitis when medically suitable; the type and timing of intervention in complex cases are decided by the treating team. [1]

Seek urgent assessment — and do not wait for a medicine or a recipe to work — if you have:

Severe or continuous pain in the upper abdomen lasting several hours, especially if it is getting worse.
Fever or shivering, or yellowing of the eyes or skin, or very dark urine.
Repeated vomiting or inability to drink fluids.
Severe pain spreading to the back, or severe dizziness, fainting or general deterioration.

For chest pain or shortness of breath, seek emergency care as well; do not assume it is gallbladder pain.

Useful questions to ask your doctor

Does the pain match biliary colic, or should another cause be looked for?
Are there stones in the duct, or signs of inflammation or blockage?
Is structured observation suitable for me, and what are the signs that the plan must change?
If dissolution medicine is discussed: are the type and size of my stones suitable, what is the follow-up plan, and how likely are the stones to return?
What are the risks of surgery and anaesthesia for my particular case, and what symptom improvement can be expected?

In summary: observation may be enough for silent stones and can suit some uncomplicated cases after discussion with the surgeon. Medical dissolution is a limited option, not routine treatment, and lithotripsy and popular recipes are not reliable equivalent alternatives. Duct endoscopy and drainage treat different problems in specific situations. The right decision balances your symptoms, your imaging and the risks of intervention — not a success rate taken out of context.

More reading: Laparoscopic cholecystectomy guide: preparation and recovery, What should you eat after gallbladder surgery?, and contact the clinic.

Medical sources and the limits of this review

The review relied on the available guidance and the following sources, together with the C-GALL and SECURE trials, which are more recent than the cited NICE and EASL guidance. No newer comprehensive guidance replacing these two was found in the search; that does not guarantee every new medical publication has been captured. The age of a guideline does not automatically make all of its recommendations outdated, and a new study alone does not mean a guideline recommendation has changed. The figures are not a personal prediction, and the article needs the doctor's approval before wide publication.