Gallstones (Cholelithiasis)

How gallstones form

The liver makes bile to help digest fat. Bile contains cholesterol, bile salts, lecithin and bilirubin (a breakdown product of red blood cells). Between meals it is stored and concentrated in the gallbladder. Stones form when:

• bile contains more cholesterol than bile salts can keep dissolved
• the gallbladder does not empty fully or often enough, so bile sits and thickens into "sludge"
• there is excess bilirubin from red cell breakdown

Types of gallstones

Stones range from grains of sand to golf-ball size, and you can have one or hundreds.

Risk factors

The traditional memory aid is "female, fat, fertile, forty," but many people outside these groups get gallstones.

• Female sex: estrogen raises bile cholesterol. Women are about twice as likely as men to have them.
• Age over 40.
• Pregnancy and estrogen-containing medicines.
• Obesity and metabolic syndrome.
• Rapid weight loss, very low calorie diets and weight-loss surgery.
• Family history and ethnicity: very common in Indigenous peoples of the Americas and in Mexican Americans.
• Diabetes, Crohn's disease affecting the end of the small bowel, cirrhosis and hemolytic anemias.
• Certain medicines: fibrates, ceftriaxone, octreotide.
• Long periods of fasting or IV nutrition.

Symptoms

About 80% of gallstones are "silent" and are found by chance on scans. Each year, only about 1 to 4% of people with silent stones develop symptoms. When symptoms appear, the typical one is biliary colic: steady pain in the upper right or central belly lasting 30 minutes to a few hours. For a detailed description of attacks and what to do, see gallstone symptoms.

Complications

• Acute cholecystitis: a stone stuck in the gallbladder neck causes inflammation and often infection, with pain lasting over 6 hours, fever and tenderness.
• Choledocholithiasis: a stone moves into the common bile duct, causing jaundice and pain.
• Acute cholangitis: infection behind a blocked bile duct. It causes fever, jaundice and pain, and can cause sepsis.
• Acute pancreatitis: a stone blocks the pancreatic duct opening. Gallstones are the leading cause of acute pancreatitis.
• Gallstone ileus: rarely, a large stone erodes into the bowel and blocks it, usually in older people.
• Gallbladder cancer: a rare long-term risk, higher with very large stones or a calcified "porcelain" gallbladder.

Diagnosis

1. Abdominal ultrasound: the first-choice test. It detects over 95% of gallbladder stones and shows gallbladder wall thickening or a widened bile duct.
2. Blood tests: liver function tests (bilirubin, alkaline phosphatase, ALT), a blood count for infection, and lipase for pancreatitis.
3. MRCP: a special MRI that maps the bile ducts and finds duct stones.
4. Endoscopic ultrasound (EUS): an ultrasound probe on an endoscope, very accurate for small duct stones.
5. HIDA scan: a nuclear scan that shows whether the gallbladder is blocked (cholecystitis) or empties poorly.
6. CT scan: good for complications but misses many gallstones.

Treatment

Silent gallstones

No treatment is usually needed. Exceptions where surgery may be considered include a porcelain gallbladder, very large stones (over 3 cm), gallbladder polyps over 1 cm, or some people having other abdominal surgery.

Symptomatic gallstones

Laparoscopic cholecystectomy (keyhole removal of the gallbladder) is recommended for most people who have had typical attacks, because attacks tend to recur and complications become more likely.

• performed under general anesthetic through 3 or 4 small cuts
• usually a day case or one-night stay
• return to desk work in about 1 to 2 weeks, and to heavy lifting in 4 to 6 weeks
• open surgery is needed occasionally, for example with severe inflammation or scarring

Acute cholecystitis

Treatment includes IV fluids, pain relief and antibiotics, with cholecystectomy ideally during the same admission, within about a week. People too unwell for surgery may have a drain placed into the gallbladder through the skin.

Bile duct stones

ERCP (endoscopic retrograde cholangiopancreatography) passes an endoscope through the mouth to the bile duct opening, where stones are removed with a balloon or basket. It is usually followed by gallbladder removal. Urgent ERCP is used for cholangitis.

Non-surgical options

• Ursodeoxycholic acid tablets can slowly dissolve small cholesterol stones in a gallbladder that still works, but treatment takes months to years and stones often return. It is mainly used for people who cannot have surgery or to prevent stones during rapid weight loss.
• Shockwave lithotripsy is rarely used now.

Life after gallbladder removal

You can live normally without a gallbladder. Bile flows directly from the liver into the bowel. Some people notice looser stools or urgency after fatty meals for a few weeks or months. A minority have ongoing symptoms, sometimes called post-cholecystectomy syndrome, which can be due to a retained bile duct stone, bile acid diarrhea or a different original cause such as reflux or IBS.

Prevention

• keep a healthy weight and lose weight gradually
• avoid long fasting and very low calorie crash diets
• stay physically active
• eat regular meals with fiber, and favor unsaturated fats over saturated fats
• some evidence suggests coffee and moderate nut intake are associated with lower risk

Frequently asked questions

What causes gallstones?

Gallstones form when bile contains too much cholesterol or bilirubin and not enough bile salts to keep it dissolved, or when the gallbladder does not empty well. Risk factors include being female, over 40, pregnant, overweight, losing weight rapidly and having a family history.

Do gallstones always need surgery?

No. Gallstones that cause no symptoms usually need no treatment. Surgery is recommended once stones cause typical attacks of pain or complications such as cholecystitis or pancreatitis, because further attacks are likely.

Can gallstones pass on their own?

Small stones sometimes pass from the gallbladder through the bile duct into the bowel. This can cause pain, jaundice or pancreatitis on the way. Stones remaining in the gallbladder do not disappear by themselves, and no diet or cleanse has been shown to flush them out.

How long is recovery after gallbladder removal?

After keyhole surgery, most people go home the same day or the next day, return to light activity and desk work in 1 to 2 weeks, and resume heavy lifting and strenuous exercise in about 4 to 6 weeks. Open surgery takes longer, about 6 to 8 weeks.

Can you get gallstones after your gallbladder is removed?

Stones cannot form in a gallbladder that is no longer there, but they can occasionally form in, or be left behind in, the bile ducts. These can cause pain or jaundice and are usually removed by ERCP.