Gallstones

What are they?

Gallstones are hard, pebble-like pieces of material that form in the gallbladder, usually made of cholesterol or bilirubin. Doctors sometimes call them cholelithiasis.

They range from the size of a grain of sand to a golf ball; there may be one large stone, hundreds of tiny stones, or a mix of both.

The gallbladder is a small, pear-shaped organ below the liver that stores bile, which the liver makes and which is mostly cholesterol, bile salts and bilirubin.

Stones can also form in the bile ducts that connect the gallbladder to the liver and pancreas, and they usually cause pain only when they block a duct (NHS).

They are common: 10 to 15 percent of the U.S. population according to NIDDK, and more than 1 in 10 adults in the UK according to the NHS. The sources of this page give no figures for the Gulf countries.

Causes

According to NIDDK, stones may form if bile contains too much cholesterol, too much bilirubin or not enough bile salts, or if the gallbladder does not empty completely or often enough. Researchers do not fully understand why these changes happen.

Cholesterol stones

• The most common type: usually yellow-green and made mostly of hardened cholesterol (NIDDK).
• They are not related to the cholesterol level in the blood (MedlinePlus).

Pigment stones

• Dark and made of bilirubin (NIDDK).
• They form when bile holds too much bilirubin, often because too many red blood cells are being destroyed (MedlinePlus).

Some people have both kinds (NIDDK).

Risk factors

• Women, especially with extra oestrogen from pregnancy, hormone therapy or birth control pills (NIDDK).
• Older age; the NHS and MedlinePlus mention being over 40.
• A family history (NIDDK).
• Obesity, especially in women, and losing weight quickly, including after weight-loss surgery (NIDDK and NHS).
• A diet high in calories and refined carbohydrates and low in fibre (NIDDK), or high in fat and low in fibre (NHS).
• Related conditions: cirrhosis, bile duct infections, haemolytic anaemias such as sickle cell disease, some intestinal diseases such as Crohn's disease, high triglycerides and low HDL cholesterol, metabolic syndrome, and diabetes and insulin resistance (NIDDK).
• Long-term intravenous feeding, an organ transplant, and a gallbladder that does not empty properly, which is more likely during pregnancy (MedlinePlus).

Symptoms

Most stones block nothing and cause no pain; they are called silent gallstones and are often found by chance on a scan done for another reason (NIDDK and MedlinePlus).

If a stone blocks a bile duct, it causes a gallbladder attack (biliary colic):

• Sudden pain in the upper right abdomen (NIDDK), or in the middle of the tummy or just under the ribs on the right (NHS).
• It usually lasts longer than 30 minutes and can go on for several hours (NHS), and usually stops when the stone moves and no longer blocks the duct (NIDDK).
• Attacks often follow heavy meals and usually happen in the evening or at night; after one attack, more are likely (NIDDK).
• There may be nausea and vomiting, and pain may be felt in the back or just under the right arm (MedlinePlus).

If a duct stays blocked for more than a few hours, complications may develop (NIDDK); their signs include fever, jaundice (yellow skin or whites of the eyes) and pale, clay-coloured stools (MedlinePlus).

Complications

The NHS says complications of gallstones are rare; they come from a blockage that causes inflammation. The main ones are:

Acute cholecystitis

• It usually happens when a stone blocks the cystic duct; gallstones cause around 95% of cases (NHS).
• The pain is sudden and sharp in the upper right tummy, spreads towards the right shoulder and usually does not go away within a few hours; there may be a high temperature, nausea and sweating (NHS).
• It is usually treated in hospital, and the gallbladder is then often removed by keyhole surgery (NHS).

A stone in the common bile duct

• About 1 in 7 people with gallstones develop one, and it can also happen after gallbladder removal (MedlinePlus).
• It causes constant, intense pain in the upper abdomen that may spread to the back near the right shoulder blade, with fever, jaundice and pale stools (MedlinePlus).
• The outcome is usually good if it is found and treated early (MedlinePlus).

Bile duct infection (cholangitis)

• An infection of the bile ducts, most often when a stone blocks them; symptoms include upper abdominal pain, fever and chills, dark urine and jaundice (MedlinePlus).
• Quick diagnosis and treatment are very important (MedlinePlus).

Pancreatitis

• Gallstones are one of the most common causes of acute pancreatitis, because they can block the opening of the pancreas (NHS).
• Most people recover fully (NHS).

NIDDK notes that untreated gallstones can be fatal when they cause complications, so do not ignore the warning signs below.

How is it diagnosed?

The doctor starts by asking about symptoms, other conditions, family history and diet, then examines the abdomen for pain (NIDDK).

• Ultrasound: the best test for finding gallstones; it is safe and painless and can show silent stones (NIDDK).
• Blood tests: show signs of infection or inflammation of the bile ducts, gallbladder, pancreas or liver, including bilirubin, liver function tests, a complete blood count and amylase or lipase (NIDDK and MedlinePlus).
• CT scan: shows complications such as infection and blockage but can miss gallstones; cholesterol stones do not show on CT although they show on ultrasound (NIDDK and MedlinePlus).
• MRI and MRCP: show stones in the bile ducts; MRCP is the most accurate non-invasive test for a common bile duct stone (NIDDK and MedlinePlus).
• HIDA scan (cholescintigraphy): shows abnormal gallbladder contractions or a blocked bile duct (NIDDK).
• ERCP (endoscopy with x-rays): more invasive and used selectively, usually to remove a stone lodged in the common bile duct (NIDDK).

• Ultrasound (sonography)Procedure
• CT scan (computed tomography)Procedure
• MRI scan (magnetic resonance imaging)Procedure
• EndoscopyProcedure
• Liver function testsLab test
• Lipase testLab test
• Complete blood count (CBC)Lab test

Treatment

If gallstones cause no symptoms, they usually need no treatment (NIDDK), though follow-up appointments may be arranged (NHS).

The main treatment for stones that cause symptoms or complications is removing the gallbladder (NHS):

• Keyhole (laparoscopic) removal is the most common method: a few small cuts under general anaesthetic; the operation usually takes about an hour and most people go home the same day or the next (NHS and MedlinePlus).
• Open surgery with one larger cut is used when the gallbladder is very inflamed or keyhole surgery is not possible; recovery takes longer, with up to a week in hospital and about a month to return to normal activity (NHS and NIDDK).
• A common bile duct stone is removed with surgery, or with ERCP and a small cut into the sphincter muscle so the stones can pass or be taken out (MedlinePlus).

While waiting for surgery, the doctor may advise painkillers, avoiding foods that trigger symptoms, and a low-fat diet (NHS).

Treatment without surgery is limited: bile acid medicines (ursodiol and chenodiol) dissolve only cholesterol stones, work best on small ones and are used only in special situations; they may take months or years, and stones can return once they are stopped. Pigment stones usually need surgery (NIDDK and MedlinePlus).

Treatments are named here as commonly used options, not as a prescription. The doctor decides the plan and the dose for each person; do not change any medicine without a professional.

Living with it

You can live without a gallbladder and keep eating a normal, healthy diet after it is removed (NHS), and nearly all people who have it removed do not have their symptoms return (MedlinePlus).

A small number of people notice softer, more frequent stools because bile reaches the intestine more often; these changes are usually temporary (NIDDK). Some people have nausea, indigestion, pain or diarrhoea after surgery that usually improves soon; if it continues, see your doctor (NHS).

• After keyhole surgery most people return to normal physical activity in about a week (NIDDK) and may return to work after 1 to 2 weeks, depending on the job (NHS).
• Someone should take you home and stay with you for the first 24 hours; small meals may be easier at first (NHS).
• Do not drive until you can do an emergency stop without pain (NHS).

Prevention

MedlinePlus says gallstones usually cannot be prevented, but the risk can be lowered (NIDDK):

• Keep a healthy weight and avoid rapid weight loss; very low-calorie diets and weight-loss surgery raise the risk, and gradual weight loss is better (NIDDK and NHS).
• Eat more high-fibre foods: fruit, vegetables, beans and whole grains (NIDDK).
• Eat fewer refined carbohydrates and less sugar, choose healthy fats such as olive oil and fish oil, and avoid the unhealthy fats in desserts and fried foods (NIDDK).
• Regular physical activity (NIDDK and NHS).

Talk with a health professional before changing your eating plan (NIDDK). The sources of this page do not support gallbladder 'cleanses' with oil and lemon or herbs as a treatment.

Common questions