Recent advance in our understanding of the natural history of gallston
es and the introduction of new treatment options have dramatically alt
ered the approach to gallstone management. Most patients with cholelit
hiasis are asymptomatic, and for them, expectant management is now rec
ommended by many authorities. This approach may also be acceptable for
some patients who have only occasional episodes of biliary colic. Lap
aroscopic cholecystecgtomy is preferred for patients who have had repe
ated episodes of biliary colic or acute cholecystitis and who are suit
able operative candidates. Nonsurgical options include oral dissolutio
n therapy with bile acids, extracorporeal shock wave lithotripsy, and
contact dissolution with methyl tertbutyl ether. Each has significant
limitations but may be considered for selected patients with symptomat
ic gallstones who are not candidates for general anesthesia or who ref
use surgery Future improvements in non-surgical therapies may ultimate
ly expand their use.