Gallstones

Your gallbladder is part of your digestive system and is a pear-shaped organ that is located on the right side of your body, just below your liver. It stores and releases a liquid called bile which your liver produces to help break down fats. Bile passes from your liver to your gallbladder via small tubes called bile ducts. Bile is concentrated in the gallbladder to make it more effective at digesting fat. It passes from your gallbladder into your small intestine, which is where it breaks down fats in the food you have eaten. 

Sometimes bile can react with fatty substances and harden to create small stones in your gallbladder called gallstones — gallstones vary in size, from as small as a grain of sand to as large as a golf ball. Gallstones are very common, with one in three women and one in five men having gallstones at some point. You may develop one gallstone or several at the same time. In most cases, gallstones are symptomless and treatment is not needed — most people don’t even know they have them.

However, sometimes a gallstone becomes trapped in a bile duct, causing sudden, severe pain in your upper abdomen. This is gallstone disease and the gallstone pain is called biliary colic.

You may only have biliary colic once, with the troublesome gallstone passing naturally from your body. Or, it may happen now and again, perhaps after eating greasy or fatty food.

Painful gallstone disease is often successfully treated with surgery.

The most common type of gallstones is cholesterol gallstones, which are usually yellow and made of predominantly undissolved cholesterol. Pigment gallstones are less common, dark brown or black, and occur when your bile contains too much bilirubin — bilirubin is made when your red blood cells are broken down. 

Gallstones are mostly symptomless and won’t cause you any problems. However, a trapped gallstone may trigger an episode of biliary colic. You’ll feel a sudden, severe pain, just below your ribs, in the centre and right-hand side of your abdomen. This pain may spread to your right shoulder and back, between your shoulder blades. 

Biliary colic pain can last from a few minutes to several hours and is not relieved by opening your bowels, passing wind or vomiting. It can happen in the day or night and can wake you up if you are sleeping. However, it is sometimes triggered by eating fatty foods.  

You may only ever experience biliary colic once or may have weeks or months between bouts of biliary colic. 

Other symptoms of gallstones include: 

• Clay-coloured stools and dark urine
• Confusion
• Excessive sweating, chills and shivering
• Gastrointestinal symptoms — this includes: 
• Burping
• Diarrhoea
• Indigestion
• Nausea 
• Vomiting
• Itchy skin
• Loss of appetite

Occasionally, gallstones lead to complications that need urgent medical attention. This can include inflammation of the gallbladder (cholecystitis), which can cause:

• A fever
• Abdominal pain
• Continual pain
• Jaundice — yellowing of your skin or the whites of your eyes; this occurs in one in seven people with cholecystitis
• Pancreatitis — inflammation of your pancreas 
• Vomiting

Cholecystitis that comes on suddenly (acute cholecystitis) is sometimes caused by an infection. Treatment, therefore, includes antibiotics to resolve the infection followed by gallbladder removal surgery, which is a type of keyhole surgery. 

If you have a more severe infection, you may also develop a gallbladder abscess (empyema of the gallbladder). This is still treated with antibiotics but the abscess may also need to be drained. 

Severe cholecystitis can cause your gallbladder to tear, which leads to peritonitis (inflammation of the inner lining of your abdomen).

If you are having regular episodes of gallstone pain, make an appointment to see your GP. Also, contact your GP immediately if you have any of the following symptoms: 

• Fever and chills 
• Gallstone pain that lasts longer than eight hours
• Jaundice 
• Severe abdominal pain ie intense pain that is not relieved no matter what position you are in

Acute cholecystitis

This occurs when a bile duct becomes permanently blocked, causing bile to accumulate in your gallbladder. Your gallbladder then becomes inflamed and infected. 

Jaundice

If your gallstone blocks a bile duct and consequently reduces bile flow, you may develop jaundice. Symptoms include itchy skin (pruritus), yellowing of your skin and eyes, dark brown urine and pale stools.

Acute cholangitis

This refers to bacterial infection of your bile ducts and can occur if they become blocked. Symptoms include upper abdominal pain that spreads to your shoulder blades, chills, confusion, feeling unwell, fever, itchy skin (pruritus) and jaundice.

Acute pancreatitis

This occurs when your gallstone blocks the opening to your pancreas, causing your pancreas to become inflamed. Symptoms include a sudden severe dull pain around the top of your stomach (upper centre of your abdomen), nausea, vomiting, diarrhoea, loss of appetite, fever and tenderness of your abdomen. You may also develop jaundice but this is less common. 

Gallbladder cancer 

Around 1,100 new cases of gallbladder cancer occur every year in the UK and having gallstones is a major risk factor. Other risk factors include a family history of gallbladder cancer and high calcium levels in your gallbladder. If your doctor thinks you are at high risk of developing gallbladder cancer, they may recommend removing your gallbladder as a preventative measure, even if you have no gallstones symptoms. 

Gallstone ileus

This refers to the formation of an abnormal channel called a fistula between your gallbladder and bowel. Gallstones travel through the fistula and block your bowel. Symptoms include abdominal pain and swelling, constipation and vomiting. A blockage in your bowel is a medical emergency and needs treatment. 

Your GP will ask about your symptoms and may perform the Murphy’s sign test. This is a physical examination of your abdomen to check if your gallbladder is inflamed. This test involves your GP placing their hand or fingers on the upper right part of your abdomen and asking you to breathe in.

They may also recommend other tests, such as blood tests to check for jaundice and an ultrasound scan to check for gallstones in your gallbladder. An ultrasound scan uses high-frequency sound waves to create images of the inside of your body. If this scan doesn’t show gallstones, you may need: 

• Cholangiography, which uses X-rays and a special dye that shows up on X-rays — the dye can be injected, using a needle, into your bloodstream or directly into your bile ducts during surgery, or it can be injected via an endoscope (a thin, telescope-like tube) that is passed into your mouth and down your gullet
• CT scan, which uses a series of X-rays at different angles to create images of the inside of your body — this is often used for emergency diagnosis if you have severe abdominal pain 
• MRI scan, which uses strong magnets and radio waves to create detailed images of the inside of your body

It’s unclear why gallstones form, but it may be due to an imbalance of the chemicals in your bile, specifically excessively high levels of cholesterol or bilirubin. This can cause small crystals to develop, which over the years slowly grow into gallstones that vary in size from as small as a grain of sand to as large as a golf ball. One or several gallstones may form. 

Four out of five cases of gallstones are cholesterol gallstones. This occurs when your liver produces more cholesterol than your gallbladder can dissolve. The excess cholesterol forms small crystals, which eventually form gallstones. 

Less commonly, pigment gallstones form. These occur when your liver produces too much bilirubin — a yellow pigment that is made from the breakdown of blood cells. This can happen as the result of several different health conditions, including biliary tract infections, liver cirrhosis and certain blood disorders.

You may also form gallstones if your gallbladder can’t empty properly eg if it doesn’t empty completely or it doesn’t empty regularly. This causes your bile to become too concentrated, which encourages gallstones to form. 

Risk factors for gallstones

Gallstones are more common once you are over 40, with women around three times more likely to have gallstones than men. You are also at a higher risk of developing gallstones if you follow a sedentary lifestyle, as well as if you:

• Are overweight or have recently lost a lot of weight through dieting or weight loss surgery 
• Are of Native American, Hispanic or Mexican descent
• Eat a high-fat, high-cholesterol and/or low-fibre diet 
• Have a close relative with gallstones
• Have certain health conditions — this includes:
• Certain blood disorders, including sickle cell anaemia or leukaemia
• Conditions that affect your bile flow eg liver cirrhosis, primary sclerosing cholangitis or obstetric cholestasis
• Crohn's disease or irritable bowel syndrome (IBS) 
• Diabetes
• Liver disease
• Take certain prescribed medications, including the contraceptive pill or the antibiotic ceftriaxone

If you are a woman, your risk also increases if you: 

• Are having high-dose oestrogen therapy
• Are pregnant
• Are taking the combined pill 
• Have had children

If your gallstones are not causing you any issues, then you may not need treatment although your doctor will recommend you attend regular check-ups to keep a close watch over your condition. Usually the longer you have no symptoms, the less likely it is that your gallstones will get worse. 

If your symptoms are mild or infrequent, lifestyle changes may be enough to prevent or reduce the frequency of symptoms. Try avoiding foods and drinks that you know have triggered symptoms in the past.

If you have another health condition that increases your risk of developing complications from gallstones, you may need treatment. Conditions that put you at risk of complications include diabetes, liver cirrhosis and portal hypertension (high blood pressure in your liver often caused by alcohol-related liver disease). Treatment may involve gallbladder removal, or medication or a procedure to remove your gallstones.

You may need to have your gallbladder removed if you have a scan that shows high calcium levels in your gallbladder — this is a risk factor for gallbladder cancer. 

Gallbladder removal surgery

If your gallstones symptoms are very painful or there are complications, your doctor may recommend gallbladder removal. This procedure is performed under general anaesthetic and has a high success rate with a low risk of complications. It is usually done via keyhole surgery, but in some cases, it may be done by open surgery.

Keyhole surgery

Gallbladder removal performed as a keyhole surgery is called a laparoscopic cholecystectomy. Your surgeon will: 

• Make three or four small cuts into your abdomen — this is the standard procedure for a laparoscopic cholecystectomy, however, a newer procedure called a single-incision laparoscopic cholecystectomy involves removing your gallbladder via just one cut into your abdomen
• Inflate your abdomen using carbon dioxide gas
• Insert a thin telescope-like tube with a camera and a light on the end (a laparascope) through one of the cuts in your abdomen to locate and see your gallbladder
• Remove your gallbladder using special surgical instruments inserted through the other small cuts in your abdomen
• Perform an X-ray or ultrasound scan if needed ie if they suspect you have a gallstone trapped in a bile duct 
• Remove any gallstones stuck in your bile ducts

If an unexpected complication occurs during your keyhole surgery or after seeing inside your body, and it becomes apparent that your surgery can't be completed this way, your procedure may be converted to an open surgery. 

Keyhole surgery for gallbladder removal takes around 60-90 minutes and you can usually go home on the same day. Complete recovery from your surgery takes around 10 days. 

You may not be able to have a laparoscopic cholecystectomy if:

• You are a woman in the third trimester of pregnancy
• You are very overweight or obese
• Your gallbladder or bile ducts have an unusual structure that makes keyhole surgery difficult or unsafe

Open surgery

If you can't have a laparoscopic cholecystectomy, open surgery may be recommended. Your surgeon will make a 10-15 cm cut into your abdomen just below your ribs so they can remove your gallbladder. You will need to stay in hospital for up to five days. Complete recovery from your surgery takes around six weeks.

Losing your gallbladder won’t affect your daily life and you won’t have to avoid any foods or drinks as your liver will still make bile.

Endoscopic retrograde cholangio-pancreatography (ERCP)

This procedure is similar to a cholangiography, which is used to diagnose gallstones and involves passing a thin, telescope-like tube with a camera and a light on the end (endoscope) into your mouth and down your gullet. However, during an ERCP, the opening to your bile duct is widened so the gallstones can be removed or allowed to pass out by themselves. This is done either using an electrically heated wire or a small cut. Gallstones do not usually return after this treatment. 

Gallstones medication

Gallstones treatment without surgery is possible in some cases if your gallstones are small and don't contain calcium. Your doctor may prescribe ursodeoxycholic acid tablets, which may dissolve your gallstones. However, these tablets are not often prescribed as they are usually not effective and must be taken for up to two years. Also, even if the tablets are effective, gallstones can return after the treatment ends.

By following a gallstones diet

A high cholesterol diet increases your risk of developing gallstones. So try to avoid eating foods with high levels of saturated fat. Instead, eat a healthy, balanced high-fibre diet, which includes lots of fresh fruit and vegetables, as well as whole grains and nuts (eg peanuts or cashews). Drinking small amounts of alcohol may also reduce your risk of gallstones — be careful not to drink in excess as this will harm your health.

By following regular mealtimes 

Fasting or skipping meals can increase your risk of developing gallstones. 

By losing excess weight and maintaining a healthy weight

Being overweight or obese increases your risk of developing gallstones. Following a healthy balanced diet alongside regular exercise can help you lose excess weight and maintain a healthy weight. Avoid rapid weight loss as this can interfere with the balance of chemicals in your bile and trigger gallstone formation.