Gallstones

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Introduction

Introduction

Gallstones are small stones, usually made of cholesterol, that form in the gallbladder. In most cases they don't cause any symptoms and don't need to be treated.

However, if a gallstone becomes trapped in an opening (duct) inside the gallbladder, it can trigger a sudden, intense abdominal pain that usually lasts between one and five hours. This type of abdominal pain is known as biliary colic.

Some people with gallstones can also develop complications, such as inflammation of the gallbladder (cholecystitis), which can cause:

When gallstones cause symptoms or complications, it's known as gallstone disease or cholelithiasis.

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The gallbladder

The gallbladder is a small, pouch-like organ found underneath the liver. Its main purpose is to store and concentrate bile.

Bile is a liquid produced by the liver to help digest fats. It's passed from the liver into the gallbladder through a series of channels known as bile ducts.

The bile is stored in the gallbladder and, over time, it becomes more concentrated, which makes it better at digesting fats. The gallbladder releases bile into the digestive system when it's needed.

What causes gallstones?

Gallstones are thought to develop because of an imbalance in the chemical make-up of bile inside the gallbladder. In most cases the levels of cholesterol in bile become too high and the excess cholesterol forms into stones.

Gallstones are very common. It's estimated that more than 1 in every 10 adults in the UK has gallstones, although only a minority of people develop symptoms.

You're more at risk of developing gallstones if you're:

  • overweight or obese 
  • female - particularly if you've had children
  • 40 or over - the risk increases as you get older

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Treating gallstones

Treatment is usually only necessary if gallstones are causing:

In these cases keyhole surgery to remove the gallbladder may be recommended. This procedure, known as a laparoscopic cholecystectomy, is relatively simple to perform and has a low risk of complications.

You can lead a perfectly normal life without a gallbladder. Your liver will still produce bile to digest food, but the bile will just drip continuously into the small intestine, rather than build up in the gallbladder.

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Outlook

Most cases of gallstone disease are easily treated with surgery. Very severe cases can be life threatening, especially in people who are already in poor health. However, deaths from gallstone disease are rare in the UK.

Cholesterol
Cholesterol is a fatty substance made by the body that is found in blood and tissue. It is used to make bile acid, hormones and vitamin D.
Gallbladder
The gallbladder is a small organ found just under the liver. It stores bile for digestion.
Inflammation
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
Jaundice
Jaundice is a condition that causes yellowing of the skin and the whites of the eyes. It is brought on by liver problems.
Liver
The liver is the largest organ inside the body. Its main jobs are to secrete bile (to help digestion), detoxify the blood and change food into energy.

Symptoms of gallstones

Symptoms of gallstones

Most cases of gallstones don't cause any symptoms. But if a gallstone blocks one of the bile ducts, it can cause sudden, severe abdominal pain, known as biliary colic.

Other symptoms may develop if the blockage is more severe or develops in another part of the digestive system.

Abdominal pain (biliary colic)

Gallstones can cause sudden, severe abdominal pain that usually lasts one to five hours (although it can sometimes last just a few minutes).

The pain can be felt:

  • in the centre of your abdomen (tummy)
  • just under the ribs on your right-hand side - it may spread from here to your side or shoulder blade

The pain is constant and isn't relieved when you go to the toilet, pass wind or are sick. It's sometimes triggered by eating fatty foods, but may occur at any time of day and it may wake you up during the night.

Biliary colic doesn't happen often. After an episode of pain, it may be several weeks or months before you experience another episode.

Some people also have periods where they sweat excessively and feel sick or vomit.

When gallstones cause episodes of biliary colic, it is known as 'uncomplicated gallstone disease'.

Other symptoms

In a small number of people, gallstones can cause more serious problems if they obstruct the flow of bile for longer periods or move into other organs (such as the pancreas or small bowel).

If this happens, you may develop:

  • a high temperature of 38C (100.4F) or above
  • more persistent pain
  • a rapid heartbeat
  • yellowing of the skin and whites of the eyes (jaundice)
  • itchy skin
  • diarrhoea
  • chills or shivering attacks
  • confusion
  • a loss of appetite

Doctors refer to this more severe condition as 'complicated gallstone disease'.

Read more about the complications of gallstones.

When to seek medical advice

If you think you may be experiencing biliary colic, you should make an appointment with your GP.

Contact your GP immediately for advice if you develop:

  • jaundice
  • abdominal pain lasting longer than eight hours
  • a high temperature and chills
  • abdominal pain so intense that you can't find a position to relieve it

If it's not possible to contact your GP immediately, phone your local out-of-hours service or call NHS 111.


Gallbladder
The gallbladder is a small organ found just under the liver. It stores bile for digestion.
Jaundice
Jaundice is a condition that causes yellowing of the skin and the whites of the eyes. It is brought on by liver problems.

Causes of gallstones

Causes of gallstones

Gallstones are thought to be caused by an imbalance in the chemical make-up of bile inside the gallbladder. Bile is a liquid produced by the liver to aid digestion.

It's still unclear exactly what leads to this imbalance, but gallstones can form if:

  • there are unusually high levels of cholesterol inside the gallbladder (about four in every five gallstones are made up of cholesterol)
  • there are unusually high levels of a waste product called bilirubin inside the gallbladder (about one in every five gallstones is made up of bilirubin)

These chemical imbalances cause tiny crystals to develop in the bile. These can gradually grow (often over many years) into solid stones that can be as small as a grain of sand or as large as a pebble.

Sometimes only one stone will form, but there are often several at the same time.

Who's at risk?

Gallstones are more common if you:

  • are female, particularly if you've had children, are taking the combined Pill, or are undergoing high-dose oestrogen therapy
  • are overweight or obese
  • are aged 40 years or older (the older you are, the more likely you are to develop gallstones)
  • have a condition that affects the flow of bile - such as cirrhosis (scarring of the liver), primary sclerosing cholangitis, or obstetric cholestasis 
  • have Crohn's disease or irritable bowel syndrome (IBS)
  • have a close family member who's also had gallstones
  • have recently lost weight (from either dieting or weight-loss surgery)
  • are taking an antibiotic called ceftriaxone


Diagnosing gallstones

Diagnosing gallstones

Gallstones may be discovered during tests for a different condition, as they often don't cause any symptoms.

If you do have symptoms of gallstones, make an appointment with your GP so they can try to identify the problem.

Seeing your GP

Your GP will ask about your symptoms in detail and may carry out the Murphy's sign test to help determine if your gallbladder is inflamed.

During this test, your GP places their hand or fingers on the upper-right area of your tummy and asks you to breathe in. If you find this painful, it usually means your gallbladder is inflamed and you may need urgent treatment.

Your GP may also recommend having blood tests to look for signs of infection, or to check if your liver is working normally. If gallstones have moved into your bile duct, the liver may not be able to function properly.

Further tests

If your symptoms and test results suggest you may have gallstones, you'll usually be referred for further tests. You may be admitted to hospital for tests the same day if your symptoms suggest you have a more severe form of gallbladder disease.

Ultrasound scan

Gallstones can usually be confirmed using an ultrasound scan, which uses high frequency sound waves to create an image of the inside of the body.

The type of ultrasound scan used for gallstones is similar to the scan used during pregnancy, where a small handheld device called a transducer is placed onto your skin and moved over your upper abdomen.

Sound waves are sent from the transducer, through your skin and into your body. They bounce back off the body tissues, forming an image on a monitor. This is a painless procedure that usually takes about 10-15 minutes to complete.

When gallstones are diagnosed, there may be some uncertainty about whether any stones have passed into the bile duct.

Gallstones in the bile duct are sometimes seen during an ultrasound scan. If they're not visible but your tests suggest the bile duct may be affected, you may need an MRI scan or a cholangiography.

MRI scan

A magnetic resonance imaging (MRI) scan may be carried out to look for gallstones in the bile ducts. This type of scan uses strong magnetic fields and radio waves to produce detailed images of the inside of the body.

Cholangiography

A procedure called a cholangiography can give further information about the condition of your gallbladder.

A cholangiography uses a dye that shows up on X-rays. The dye may be injected into your bloodstream or injected directly into your bile ducts during surgery or using an endoscope passed through your mouth.

After the dye has been introduced, X-ray images are taken. They'll reveal any abnormality in your bile or pancreatic systems. If your gallbladder and bile systems are working normally, the dye will be absorbed in the places it's meant to go (your liver, bile ducts, intestines and gallbladder).

If a blockage is detected during this test, your doctor may try to remove it at this point using an endoscope. This is known as an endoscopic retrograde cholangio-pancreatography (ERCP). See treating gallstones for more information about ERCP.

CT scan

A computerised tomography (CT) scan may be carried out to look for any complications of gallstones, such as acute pancreatitis. This type of scan involves taking a series of X-rays from many different angles.

CT scans are often done in an emergency to diagnose severe abdominal pain.


Treating gallstones

Treating gallstones

Your treatment plan for gallstones depends on how the symptoms are affecting your daily life.

If you don't have any symptoms, a policy of 'active monitoring' is often recommended. This means you won't receive immediate treatment, but you should let your GP know if you notice any symptoms.

As a general rule, the longer you go without symptoms, the less likely it is that your condition will get worse.

You may need treatment if you have a condition that increases your risk of developing complications, such as:

Treatment may also be recommended if a scan shows high levels of calcium inside your gallbladder, as this can lead to gallbladder cancer in later life.

If you have episodes of abdominal pain (biliary colic), treatment depends on how the pain affects your daily activities. If the episodes are mild and infrequent, you may be prescribed painkillers to control further episodes and given advice about eating a healthy diet to help control the pain.

If your symptoms are more severe and occur frequently, surgery to remove the gallbladder is usually recommended.

The gallbladder isn't an essential organ and you can lead a perfectly normal life without one. Some people may experience symptoms of bloating and diarrhoea after eating fatty or spicy food. If certain foods do trigger symptoms, you may wish to avoid them in the future.

Keyhole surgery to remove the gallbladder

If surgery is recommended, you'll usually have keyhole surgery to remove your gallbladder. This is known as a laparoscopic cholecystectomy.

During a laparoscopic cholecystectomy, three or four small cuts are made in your abdomen. One larger cut (about 2-3cm) will be by the belly button and the others (each 1cm or less) will be on the right side of your abdomen.

Your abdomen is temporarily inflated using carbon dioxide gas. This is harmless and makes it easier for the surgeon to see your organs.

laparoscope (long thin telescope with a tiny light and video camera at the end) is inserted through one of the cuts in your abdomen. This allows your surgeon to view the operation on a video monitor. Your surgeon will then remove your gallbladder using special surgical instruments.

If it's thought there may be gallstones in the bile duct, an X-ray or ultrasound scan of the bile duct is also taken during the operation. If gallstones are found, they may be removed during keyhole surgery. If the operation can't be done this way or an unexpected complication occurs, it may have to be converted to open surgery (see below).

After the gallbladder has been removed, the gas in your abdomen escapes through the laparoscope and the cuts are closed with dissolvable stitches and covered with dressings.

Laparoscopic cholecystectomies are usually performed under a general anaesthetic, which means you'll be asleep during the procedure and won't feel any pain while it's carried out. The operation takes 60-90 minutes and you can usually go home the same day. Full recovery typically takes around 10 days.

Single-incision keyhole surgery

Single-incision laparoscopic cholecystectomy is a newer type of keyhole surgery used to remove the gallbladder. During this type of surgery, only one small cut is made, which means you'll only have one barely visible scar.

However, single-incision laparoscopic cholecystectomies haven't been carried out as often as conventional laparoscopic cholecystectomies, so there are still some uncertainties about it. Access to this type of surgery is also limited because it needs an experienced surgeon with specialist training.

The National Institute for Health and Care Excellence (NICE) has more information on single-incision laparoscopic cholecystectomy.

Open surgery

A laparoscopic cholecystectomy may not always be recommended, for example if you:

  • are in the third trimester (the last three months) of pregnancy
  • are extremely overweight
  • have an unusual gallbladder or bile duct structure that makes a keyhole procedure difficult and potentially dangerous

In these circumstances, an open cholecystectomy may be recommended. During this procedure, a 10-15cm (4-6in) incision is made in your abdomen underneath the ribs so the gallbladder can be removed. This is done under general anaesthetic, so you'll be asleep and won't feel any pain.

Open surgery is just as effective as laparoscopic surgery, but it does have a longer recovery time and causes more visible scarring. Most people have to stay in hospital for up to five days and it typically takes six weeks to fully recover.

Read more about recovering from gallbladder surgery.

Endoscopic retrograde cholangio-pancreatography (ERCP)

An endoscopic retrograde cholangio-pancreatography (ERCP) is a procedure that can be used to remove gallstones from the bile duct. The gallbladder isn't removed during this procedure, so any stones in the gallbladder will remain unless removed using the surgical techniques mentioned above.

ERCP is similar to a diagnostic cholangiography (see diagnosing gallstones for more information), where an endoscope (long, thin flexible tube with a camera at the end) is passed through your mouth down to where the bile duct opens into the small intestine.

However, during ERCP the opening of the bile duct is widened with a small incision or an electrically heated wire. The bile duct stones are then removed or left to pass into your intestine and out of your body.

Sometimes a small tube called a stent is permanently placed in the bile duct to help the bile and stones pass.

An ERCP is usually carried out under sedation, which means you'll be awake throughout the procedure but won't experience any pain.

The ERCP procedure lasts about 30 minutes on average, but can take from 15 minutes to over an hour. You may need to stay overnight in hospital after the procedure so you can be monitored.

Medication to dissolve gallstones

If your gallstones are small and don't contain calcium, it may be possible to take ursodeoxycholic acid tablets to dissolve them.

However, these aren't prescribed very often because:

  • they're rarely very effective
  • they need to be taken for a long time (up to two years)
  • gallstones can recur once treatment is stopped

Side effects of ursodeoxycholic acid are uncommon and are usually mild. The most commonly reported side effects are feeling sick, being sick and itchy skin.

The use of ursodeoxycholic acid isn't usually recommended for pregnant or breastfeeding women. Sexually active women should use either a barrier method of contraception, such as a condom, or a low-dose oestrogen contraceptive pill while taking ursodeoxycholic acid, as it may affect other types of oral contraceptive pills.

Ursodeoxycholic acid tablets are occasionally also prescribed as a precaution against gallstones if it's thought you're at risk of developing them. For example, you may be prescribed ursodeoxycholic acid if you've recently had weight loss surgery, as rapid weight loss can cause gallstones to grow.

 

Cholesterol
Cholesterol is a fatty substance made by the body that is found in blood and tissue. It is used to make bile acid, hormones and vitamin D.

Complications of gallstones

Complications of gallstones

A small number of people with gallstones may develop serious problems if the gallstones cause a severe blockage or move into another part of the digestive system.

Inflammation of the gallbladder (acute cholecystitis)

In some cases of gallstone disease a bile duct can become permanently blocked, which can lead to a build-up of bile inside the gallbladder. This can cause the gallbladder to become infected and inflamed.

The medical term for inflammation of the gallbladder is acute cholecystitis. Symptoms include:

  • pain in your upper abdomen that travels towards your shoulder blade (unlike biliary colic, the pain usually lasts longer than five hours)
  • a high temperature (fever) of 38C (100.4F) or above
  • a rapid heartbeat

An estimated one in seven people with acute cholecystitis also experience jaundice (see below).

Acute cholecystitis is usually treated first with antibiotics to settle the infection and then keyhole surgery to remove the gallbladder. This operation can be more difficult when performed as an emergency and there's a higher risk of it being converted to an open procedure.

Sometimes a severe infection can lead to a gallbladder abscess (empyema of the gallbladder). Antibiotics alone don't always treat these and they may need to be drained.

Occasionally a severely inflamed gallbladder can tear, leading to peritonitis (inflammation of the inside lining of the abdomen). If this happens, you may need to have antibiotics given directly into a vein (intravenous antibiotics) and surgery may be required to remove a section of the lining if part of it becomes severely damaged.

Read more about acute cholecystitis.

Jaundice

If a gallstone passes out of the gallbladder into the bile duct and blocks the flow of bile, jaundice occurs.

Symptoms of jaundice include:

  • yellowing of the skin and eyes
  • dark brown urine
  • pale stools
  • itching

Sometimes the stone passes from the bile duct on its own. If it doesnt, the stone needs to be removed. See treating gallstones.

Infection of the bile ducts (acute cholangitis)

If the bile ducts become blocked, they're vulnerable to infection by bacteria. The medical term for a bile duct infection is acute cholangitis.

Symptoms of acute cholangitis include:

  • pain in your upper abdomen that travels towards your shoulder blade
  • a high temperature
  • jaundice
  • chills
  • confusion
  • itchy skin
  • generally feeling unwell

Antibiotics whelp treat the infection, but it's also important to help the bile from the liver to drain with an endoscopic retrograde cholangio-pancreatography (ERCP). See treating gallstones for more information.

Acute pancreatitis

Acute pancreatitis may develop when a gallstone moves out of the gallbladder and blocks the opening (duct) of the pancreas, causing it to become inflamed.

The most common symptom of acute pancreatitis is a sudden severe dull pain in the centre of your upper abdomen, around the top of your stomach.

The pain of acute pancreatitis often gets steadily worse until it reaches a constant ache. The ache may travel from your abdomen and along your back and may feel worse after you have eaten. Leaning forward or curling into a ball may help to relieve the pain.

Other symptoms of acute pancreatitis can include:

  • feeling sick
  • being sick
  • diarrhoea 
  • loss of appetite
  • a high temperature (fever) of 38C (100.4F) or above
  • tenderness of the abdomen
  • less commonly, jaundice

There's currently no cure for acute pancreatitis, so treatment focuses on supporting the functions of the body until the inflammation has passed.

This usually involves admission to hospital so you can be given:

  • fluids into a vein (intravenous fluids)
  • pain relief
  • nutritional support
  • oxygen through tubes into your nose

With treatment, most people with acute pancreatitis improve within a week and are well enough to leave hospital after 5-10 days.

Read more about acute pancreatitis.

Cancer of the gallbladder

Gallbladder cancer is a rare but serious complication of gallstones. An estimated 660 cases of gallbladder cancer are diagnosed in the UK each year.

Having a history of gallstones increases your risk of developing gallbladder cancer. Approximately four out of every five people who have cancer of the gallbladder also have a history of gallstones.

However, people with a history of gallstones have a less than one in 10,000 chance of developing gallbladder cancer.

If you have additional risk factors, such as a family history of gallbladder cancer or high levels of calcium inside your gallbladder, it may be recommended that your gallbladder be removed as a precaution, even if your gallstones aren't causing any symptoms.

The symptoms of gallbladder cancer are similar to those of complicated gallstone disease, including:

  • abdominal pain
  • high temperature (fever) of 38C (100.4F) or above
  • jaundice

Gallbladder cancer can be treated with a combination of surgery, chemotherapy and radiotherapy.

Gallstone ileus

Another rare but serious complication of gallstones is known as gallstone ileus. This is where the bowel becomes obstructed by a gallstone.

Gallstone ileus can occur when an abnormal channel, known as a fistula, opens up near the gallbladder. Gallstones are then able to travel through the fistula and can block the bowel.

Symptoms of gallstone ileus include:

  • abdominal pain
  • being sick
  • swelling of the abdomen 
  • constipation

A bowel obstruction requires immediate medical treatment. If it's not treated, there's a risk that the bowel could split open (rupture). This could cause internal bleeding and widespread infection.

If you suspect you have an obstructed bowel, contact your GP as soon as possible. If this isn't possible, phone NHS 111.

Surgery is usually required to remove the gallstone and unblock the bowel. The type of surgery you receive depends on where in the bowel the obstruction has occurred.


Preventing gallstones

Preventing gallstones

From the limited evidence available, changes to your diet and losing weight (if you're overweight) may help prevent gallstones.

Diet

Because of the role cholesterol appears to play in the formation of gallstones, it is advisable to avoid eating too many foods with a high saturated fat content.

Foods high in saturated fat include:

  • meat pies
  • sausages and fatty cuts of meat
  • butter, ghee and lard
  • cream
  • hard cheeses 
  • cakes and biscuits
  • food containing coconut or palm oil

A healthy, balanced diet is recommended. This includes plenty of fresh fruit and vegetables (at least five portions a day) and wholegrains.

There's also evidence that regularly eating nuts, such as peanuts or cashews, can help reduce your risk of developing gallstones. 

Drinking small amounts of alcohol may also help reduce your risk of gallstones. However, you shouldn't regularly drink more than 14 units of alcohol a week as this can lead to liver problems and other health conditions. Regularly drinking any amount of alcohol can increase the risk to your health.

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Losing weight

Being overweight, particularly being obese, increases the amount of cholesterol in your bile, which increases your risk of developing gallstones. You should control your weight by eating a healthy diet and taking plenty of regular exercise.

However, avoid low-calorie, rapid-weight-loss diets. There's evidence they can disrupt your bile chemistry and increase your risk of developing gallstones. A more gradual weight loss plan is recommended.

Read more about losing weight and getting started with exercise.