Cholelithiasis (Gallstones)

How gallstones form

The gallbladder is a small pouch under the liver that stores bile, a fluid that helps digest fat. Bile contains cholesterol, bile salts and bilirubin. Stones form when bile contains too much cholesterol or bilirubin, not enough bile salts, or when the gallbladder does not empty well.

Stones range from grains of sand to golf-ball size.

Risk factors

The classic shorthand is "female, forty, fertile, fat", but many other factors matter:

• female sex (estrogen increases cholesterol in bile)
• age over 40
• pregnancy and estrogen therapy
• obesity
• rapid weight loss, very low calorie diets and weight-loss surgery
• family history, and Native American and Hispanic ancestry
• diabetes and metabolic syndrome
• Crohn's disease affecting the end of the small bowel
• cirrhosis and hemolytic anemias
• some medicines, such as ceftriaxone and octreotide

Symptoms

About 80% of people with gallstones have no symptoms ("silent gallstones"). Each year, only a small proportion develop symptoms.

Biliary colic (gallstone attack)

• steady, severe pain in the upper right belly or just below the breastbone
• pain may spread to the right shoulder blade or back
• often starts after a meal or at night
• lasts 30 minutes to a few hours, then settles
• nausea and vomiting

Despite the name, the pain is usually steady rather than coming in waves. See biliary colic.

Bloating, burping and vague indigestion are common in people with gallstones but are often not caused by them, and may persist after surgery.

Complications

Diagnosis

• Abdominal ultrasound: the main test; detects most gallbladder stones and signs of inflammation.
• Blood tests: liver function (bilirubin, ALP, ALT), blood count for infection, and lipase for pancreatitis.
• MRCP (magnetic resonance cholangiopancreatography): looks for stones in the bile ducts.
• Endoscopic ultrasound: for small duct stones.
• HIDA scan: shows whether the gallbladder fills and empties, used when cholecystitis is uncertain.

Treatment

Silent gallstones

No treatment is usually needed. Surgery may be considered in special cases, such as very large stones, a porcelain (calcified) gallbladder or some people with sickle cell disease.

Symptomatic gallstones

• Laparoscopic cholecystectomy: keyhole removal of the gallbladder is the standard treatment. Most people go home the same or next day and return to normal activities within 1 to 2 weeks. You can live normally without a gallbladder; bile flows directly from the liver to the bowel.
• Pain relief during an attack: NSAIDs such as ibuprofen or diclofenac are effective; follow medical advice.
• Acute cholecystitis: antibiotics if infected, and early surgery, ideally within about a week of symptoms.

Bile duct stones

ERCP (endoscopic retrograde cholangiopancreatography) removes stones from the bile duct through an endoscope passed through the mouth, followed by gallbladder removal.

Non-surgical options

• Ursodeoxycholic acid tablets can slowly dissolve small cholesterol stones, but stones often recur when treatment stops. It is mainly used for people who cannot have surgery or to prevent stones during rapid weight loss.
• Percutaneous cholecystostomy (a drainage tube) for very unwell people who cannot have surgery.

Diet

Smaller, lower-fat meals may reduce attacks while waiting for surgery but do not dissolve stones.

After gallbladder removal

Most people have no lasting problems. Some notice looser stools or diarrhea after fatty meals, which usually improves over weeks to months. A minority have ongoing pain, sometimes from a retained bile duct stone.

Prevention

• keep a healthy weight and avoid crash diets; aim for gradual weight loss
• stay physically active
• eat regular meals with fiber and healthy fats

Frequently asked questions

What is cholelithiasis?

Cholelithiasis is the medical name for gallstones in the gallbladder. The stones are usually made of cholesterol and form when bile becomes too concentrated. Most people with gallstones have no symptoms, but some get painful gallstone attacks or complications.

What does a gallstone attack feel like?

A gallstone attack usually causes steady, severe pain in the upper right or middle of the belly, sometimes spreading to the right shoulder blade or back. It often begins after a meal or at night, lasts from 30 minutes to several hours, and comes with nausea or vomiting.

Do gallstones always need surgery?

No. Gallstones that cause no symptoms usually do not need treatment. Surgery to remove the gallbladder is recommended for people who have gallstone attacks or complications such as cholecystitis or pancreatitis, because attacks tend to recur.

Can gallstones go away on their own?

Gallstones rarely disappear on their own. Small stones sometimes pass into the bowel, which can cause complications on the way. Medicines can dissolve some small cholesterol stones over months, but they often return when treatment stops.

Can you live without a gallbladder?

Yes. After the gallbladder is removed, bile flows directly from the liver into the small intestine. Most people digest food normally. Some have looser stools after fatty meals for a while, which usually settles.