Gallstones

Gallstones are solid deposits that form from bile. Many people have them without experiencing any symptoms; treatment is usually considered when they cause characteristic pain or lead to complications.

What are gallstones?

The gallbladder is a small organ situated beneath the liver. It stores and concentrates bile, a fluid produced by the liver that plays a part in the digestion and absorption of fats. Stones form when certain components of the bile clump together and crystallise inside the gallbladder. This condition is known medically as cholelithiasis.

A single stone or several stones may form, and their size ranges from small deposits to stones several centimetres in size. In many people, they cause no symptoms and are discovered incidentally during an ultrasound scan carried out for another reason. Their presence, on its own, does not necessarily mean that surgery is required.

Why do gallstones form?

Bile contains water, bile salts, cholesterol, bilirubin and other substances. Stones can form when their composition promotes crystallisation or when the gallbladder does not empty properly.

Most gallstones diagnosed in our region are composed mainly of cholesterol. Others, known as pigment gallstones, contain mainly bilirubin and may be linked to certain blood disorders, biliary infections or liver problems.

There is rarely a single cause. Their development results from a combination of individual predisposition, metabolism, hormonal factors and gallbladder function.

The likelihood of developing them increases with age, pregnancy, being overweight, a family history of the condition and rapid weight loss. The risk may also be higher in people with certain intestinal, liver or blood disorders. Although they are more common in women, they can affect anyone, even those without known risk factors.

What symptoms can they cause?

Most people with gallstones do not experience any symptoms. Discomfort usually occurs when a stone temporarily blocks the outlet of the gallbladder and prevents bile from flowing normally. This causes what is known as biliary pain or biliary colic.

It is usually felt under the ribs on the right-hand side or in the upper, central part of the abdomen. It may radiate to the back, the right shoulder or the area between the shoulder blades. Although the term ‘colic’ is used, the pain is usually continuous and sustained. It intensifies during the first few minutes and may last from around half an hour to several hours.

In some people, it occurs after a large or high-fat meal, but this link does not always hold true and does not, on its own, confirm that the cause lies in the gallbladder. The episode may be accompanied by nausea or vomiting. Between attacks, the person may feel perfectly well.

Warning signs and possible complications

A simple episode of biliary pain usually subsides once the stone no longer blocks the outlet of the gallbladder. It is advisable to seek prompt medical attention if the pain is severe, does not subside or persists for several hours, particularly when accompanied by:

• Fever or chills.

• Repeated vomiting.

• Yellowing of the skin or the whites of the eyes.

• Very dark urine or unusually pale stools.

• Drowsiness, confusion or a marked deterioration in general health.

These symptoms alone do not confirm the complication, but they do indicate that further investigation is required.

Acute cholecystitis

Cholecystitis is an inflammation of the gallbladder, usually caused by a persistent blockage of its outlet. It typically causes persistent pain beneath the right ribs, tenderness on palpation of the area and, frequently, a fever. It usually requires hospital care and surgical assessment.

Gallstones and infection in the biliary tract

Occasionally, a stone leaves the gallbladder and enters the main duct that carries bile to the intestine. This condition is known as choledocholithiasis. The blockage can lead to jaundice, i.e. a yellowish tinge to the skin and eyes, as well as changes in the urine, stools and liver function tests.

If the blockage is accompanied by infection, cholangitis develops – a potentially serious complication that can cause fever, chills, abdominal pain, jaundice and rapid deterioration in general health. It requires urgent treatment.

Biliary pancreatitis

The opening of the bile duct is situated very close to that of the pancreas. A stone becoming lodged in this area can trigger acute inflammation of the pancreas. Biliary pancreatitis usually causes severe pain in the upper abdomen, often radiating to the back, accompanied by nausea or vomiting.

How they are diagnosed

The assessment begins by analysing the characteristics of the pain: where it is located, how long it lasts, how it progresses and what symptoms accompany it. A physical examination may point to inflammation of the gallbladder or other causes of abdominal pain. However, symptoms alone are not sufficient to confirm the presence of gallstones.

Abdominal ultrasound

An ultrasound scan is the first test used to examine the gallbladder. It can detect most gallstones, assess the thickness of the gallbladder wall and reveal any inflammation or fluid around it. It can also show dilation of the bile ducts, which would suggest an obstruction.

It is a painless test, does not use radiation and usually provides sufficient information to confirm gallstones.

Blood tests

Blood tests cannot visualise the stones, but they help to detect their effects. They may reveal signs of inflammation or infection, abnormalities in liver function, a blockage in the bile duct or inflammation of the pancreas. In an episode of uncomplicated biliary pain, blood test results may be normal.

Biliary tract investigation

If it is suspected that a stone has passed from the gallbladder and is located in the bile duct, further tests may be necessary. Cholangiography is a specialised MRI scan that produces detailed images of the bile ducts without inserting instruments into them.

In some cases, an endoscopic ultrasound is used, which combines a gastrointestinal endoscopy with an ultrasound scan performed from within the digestive tract. A CT scan is not the primary test for diagnosing gallstones, as some stones are not clearly visible. It is mainly reserved for investigating certain complications or ruling out other causes of pain.

Asymptomatic gallstones: do they require treatment?

Stones are often discovered during an ultrasound scan carried out because of discomfort that ultimately turns out to have another cause, or during a test requested for a different reason. If they have never caused biliary pain or complications, surgery is not usually performed. Nor are regular ultrasound scans usually carried out simply to check whether the stones are growing or changing.

The approach is to adopt a ‘wait-and-see’ attitude and explain which symptoms might indicate that the stones have started to cause problems. There are rare situations in which treatment may be considered even in the absence of symptoms, but these must be assessed on a case-by-case basis and do not represent standard practice.

What is the treatment for gallstones?

Treatment depends on whether the stones cause symptoms, how often attacks occur and whether there are any complications.

Asymptomatic gallstones

Gallstones discovered incidentally do not usually require medication, surgery or follow-up imaging tests. There is no standard drug treatment that can reliably remove the stones and prevent them from forming again.

Biliary pain

During an episode, painkillers may be used and, where necessary, medication to control nausea. If the episodes have characteristics consistent with biliary pain and recur, removal of the gallbladder is usually recommended to prevent further attacks and reduce the risk of complications.

Before recommending surgery, it is important to confirm that the pattern of symptoms can reasonably be attributed to the gallbladder. The operation does not guarantee that symptoms such as bloating, acid reflux or indigestion will disappear if they have another cause.

Laparoscopic cholecystectomy

The procedure to remove the gallbladder is called a cholecystectomy. In most cases, it is performed laparoscopically, by inserting a camera and surgical instruments through small incisions in the abdomen.

It is not just the stones that are removed. The entire gallbladder is removed because, if left in place, it may form stones again and cause further episodes. Elective surgery usually has a favourable outcome. The time needed to return to work, drive or exercise depends on the patient’s recovery and the physical demands of each activity.

In certain circumstances, it may be necessary to convert the procedure to open surgery, particularly where there is significant inflammation, anatomical difficulties or safety concerns during the procedure.

Treatment of complications

Acute cholecystitis usually requires hospital treatment, pain management, hydration and, in certain situations, antibiotics. When the patient’s clinical condition permits, early cholecystectomy is considered.

If there is a stone in the bile duct, it may be necessary to remove it using endoscopic retrograde cholangiopancreatography, known as ERCP. ERCP is performed by inserting an endoscope through the mouth into the intestine. From there, the opening of the bile duct is accessed and any stones obstructing it can be removed.

ERCP treats the problem in the bile duct, but does not remove the gallbladder, where the stones usually originate. For this reason, once the obstruction has been resolved, a cholecystectomy is usually also considered.

Progression of cholelithiasis

Many people with asymptomatic gallstones never experience any discomfort. Once an episode of biliary pain has occurred, further attacks may follow. It is not possible to predict exactly when these will recur or whether complications will arise. Cholecystitis, obstruction or infection of the bile ducts, and pancreatitis are the main complications that treatment aims to prevent.

Following a cholecystectomy, stones can no longer form inside the gallbladder because the organ has been removed. However, in rare cases, stones may persist or develop in the bile ducts.

Can gallstones be prevented?

It is not always possible to prevent the formation of gallstones, as age, genetics, hormones and certain medical conditions all play a part. Maintaining a stable weight and avoiding very rapid weight loss can reduce the risk. Drastic weight loss, prolonged fasting and some procedures to treat obesity can increase the likelihood of them developing.

There is no diet that can dissolve gallstones or guarantee that they will not return. Nor is it necessary to eliminate all fats from your diet. If certain foods clearly trigger pain whilst you are undergoing tests or awaiting treatment, it may be sensible to avoid them temporarily.

Which specialist treats gallstones?

Primary care doctors can carry out an initial assessment, request an ultrasound scan and determine whether the pain is consistent with a biliary cause.

A gastroenterologist is particularly involved when there are diagnostic uncertainties, abnormalities in liver function tests, a suspicion of gallstones, or a need for specialised techniques such as endoscopic ultrasound or ERCP.

At our hospital, we have a Biliopancreatic Unit, which forms part of the Gastroenterology Department and specialises in the investigation and treatment of diseases of the biliary tract and the pancreas. The Unit enables a specialist assessment of cases requiring more detailed investigation or advanced endoscopic treatment.

When gallbladder stones cause symptoms and removal is being considered, the specialist in General and Gastrointestinal Surgery assesses the need for a cholecystectomy and determines the most appropriate time and approach for the procedure.

Where the case requires it, the Gastroenterology Department and the Department of General and Digestive Surgery can coordinate care to provide the most appropriate treatment in each situation.

Living with gallstones or after surgery

When there are no symptoms

Having asymptomatic gallstones does not usually require major changes to your daily life. You do not need to be constantly mindful of your gallbladder or follow strict dietary restrictions. The most helpful thing is to understand how biliary pain usually presents itself and what signs warrant a medical assessment.

If you have already experienced episodes, some people identify foods that trigger the discomfort. Whilst you are undergoing tests or awaiting treatment, it may be sensible to temporarily avoid these triggers without adopting excessively restrictive diets.

After gallbladder removal

The liver continues to produce bile after the operation. The difference is that, as there is no gallbladder, bile flows more continuously into the intestine. Most people gradually return to a normal diet and can resume their usual activities.

During the first few weeks, you may experience flatulence, faster digestion or changes in bowel habits. These symptoms usually improve as the body adapts. A small number of people continue to experience diarrhoea or digestive discomfort. In such cases, it is advisable to assess whether these symptoms are related to the flow of bile or whether there is another cause requiring treatment.