Gallstones

What gallstones are

Gallstones are solid stones that form inside the gallbladder, a small pouch under the liver that stores bile. Most are made largely of cholesterol; others contain bile pigment. They are common, and many people who have them never develop symptoms.

Having gallstones is not the same as having gallstone disease. The stones matter when they block the outlet of the gallbladder or move into the bile duct, because that is when pain and complications happen.

Stones without symptoms

Gallstones are often found by chance on an ultrasound arranged for another reason. When the gallbladder itself and the rest of the biliary tree look normal and there are no symptoms, NICE advises that these stones do not routinely need treatment unless symptoms develop. Individual exceptions exist and are assessed separately, so this reassurance is not a rule that removes the need for clinical judgement.

Symptomatic gallstones and their complications

Biliary colic is the typical symptom: a steady, severe pain in the upper abdomen, often on the right or in the centre, that can spread to the back or right shoulder blade, frequently starts after a meal, lasts from about half an hour to several hours, and then settles. Nausea and vomiting are common. It is a warning that stones are obstructing the gallbladder outlet, and attacks tend to come back.

Acute cholecystitis is inflammation of the gallbladder wall that follows persistent blockage of the gallbladder outlet; infection may also be present, but infection is not part of the definition. The pain does not settle in the usual way, is tender to press, and is often accompanied by fever and feeling generally unwell.

Bile-duct stones happen when a stone passes out of the gallbladder into the common bile duct. This can cause pain with jaundice, dark urine and pale stools, and abnormal liver blood tests.

Gallstone pancreatitis occurs when a stone obstructs the drainage of the pancreas, producing severe, persistent upper-abdominal pain, often spreading through to the back, especially when accompanied by repeated vomiting. It is a medical emergency.

Cholangitis is infection of an obstructed bile duct, typically with jaundice, fever, rigors and marked illness. It also needs emergency treatment.

How gallstone disease is investigated

For suspected gallstone disease NICE advises liver function tests and an ultrasound scan. If the ultrasound does not show a stone in the bile duct but the duct is dilated and/or the liver blood tests are abnormal, NICE advises considering an MRCP scan. If MRCP does not answer the question, endoscopic ultrasound may then be considered. This stepwise pathway exists precisely because a normal ultrasound does not, on its own, exclude a stone in the bile duct.

When treatment is considered

For gallbladder stones that are causing symptoms, NICE recommends laparoscopic cholecystectomy — keyhole removal of the gallbladder, not removal of the stones alone. You can read about the operation itself on the laparoscopic cholecystectomy page. For acute cholecystitis, NICE recommends early laparoscopic cholecystectomy, within 1 week of diagnosis, rather than waiting for weeks.

When there are stones in the common bile duct, the duct is cleared as part of the same treatment pathway as gallbladder removal. Depending on the clinical situation and available expertise, the duct is cleared either surgically at the time of laparoscopic cholecystectomy or by ERCP before or at the time of the operation. When ERCP cannot achieve clearance, a temporary stent may be placed in the bile duct as an interim step rather than as definitive treatment.

After mild gallstone pancreatitis, gallbladder removal is usually planned during the same hospital admission once the patient is clinically suitable; timing may differ in severe pancreatitis or when complications are present.

Medicines are not routinely used as a substitute for cholecystectomy for ordinary symptomatic gallbladder stones; treatment is individualized where special circumstances apply.

Diet

Before gallstones are treated, NICE advises avoiding food or drink that reliably triggers your symptoms. After the gallbladder or gallstones have been removed, you should not normally need to continue avoiding those trigger foods. If, once you have recovered, food or drink continues to trigger your previous symptoms, or causes new symptoms, further clinical assessment is appropriate rather than indefinite avoidance.

When the pain may not be the gallstones

Because gallstones are common, they are often present in people whose pain is coming from something else — the stomach, the duodenum, reflux, irritable bowel, the heart, or the abdominal wall. A pain pattern that does not fit biliary pain should prompt a search for another diagnosis rather than an automatic operation.