The most appropriate management for this patient's gallstones is clinical observation. Her symptoms are consistent with gastroesophageal reflux. Gallstones were incidentally found on her evaluation but are asymptomatic. Biliary colic is the most common clinical presentation in patients with symptomatic gallstones. The usual presentation of biliary colic is episodic, severe abdominal pain typically in the epigastrium and/or right upper quadrant but occasionally in the right lower or mid-abdomen. The pain rapidly intensifies over a 15-minute interval to a steady plateau that lasts as long as 3 hours and resolves slowly. The pain is often associated with nausea or vomiting, and there is no jaundice. Pain may radiate to the interscapular region or right shoulder. An estimated 60% to 80% of gallstones are asymptomatic. Over a 20-year period, 50% of patients remain asymptomatic, 30% have biliary colic, and 20% have more serious complications. Observation is recommended for adult patients with asymptomatic gallstones. The possible exceptions to this recommendation are groups at higher risk for gallbladder carcinoma, such as patients with a calcified (porcelain) gallbladder, certain American Indians, and patients with gallstones larger than 3 cm.

Risks for symptoms or complications from silent gallstones are about 2% per year and cumulative, and risks for complications in the absence of antecedent pain are minimal. Therefore, annual ultrasonography is unlikely to alter management decisions for this patient and she can be treated expectantly, based on the occurrence of symptoms.

Laparoscopic cholecystectomy is the treatment of choice for symptomatic biliary colic and acute cholecystitis. Mortality rates following laparoscopic cholecystectomy are less than 0.7%, and complication rates (including bile duct injuries) do not differ between laparoscopic and open cholecystectomy. However, this patient's pain is inconsistent with biliary pain, and neither laparoscopic nor open cholecystectomy is indicated.

Oral administration of ursodiol for dissolution of gallstones is rarely used. It can be considered in patients with symptomatic noncalcified gallbladder stones who are at high risk for cholecystectomy.