Gallstones

Gallstones

Gallstones are small stones, usually made of cholesterol, that form in the gallbladder. In most cases they do not cause any symptoms. However, if a gallstone becomes trapped in a duct (opening) 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.

The medical term for symptoms and complications related to gallstones is gallstone disease or cholelithiasis. Gallstone disease can also cause inflammation of the gallbladder (cholecystitis). This can cause persistent pain, jaundice and a high temperature (fever) of 38°C (100.4°F) or above.

In some cases a gallstone can move into the pancreas, causing it to become irritated and inflamed. This is known as acute pancreatitis and causes abdominal pain that gets progressively worse.

Gallbladder containing several gallstones of various sizes.

The gallbladder

The gallbladder is a small, pouch-like organ situated underneath the liver. The main purpose of the gallbladder is to store and concentrate bile. Bile is a liquid that is produced by the liver, which helps digest fats. It is passed from the liver through a series of channels, known as bile ducts, into the gallbladder.

The bile is stored in the gallbladder and, over time, it becomes more concentrated, which makes it better at digesting fats. The gallbladder is able to release bile into the digestive system when it is required.

Schematic diagram showing the anatomy of gallbladder, liver, pancreas and duodenum (small intestine)

Treating gallstones

Gallstone disease is relatively straightforward to treat. The most widely used treatment is keyhole surgery to remove the gallbladder. Doctors refer to this as a laparoscopic cholecystectomy. This type of surgery is generally safe with a low risk of complications. There are several non-surgical treatments that can be used to break up gallstones, but they often return at a later date. So surgery is usually the preferred option where possible.

You can lead a perfectly normal life without a gallbladder. The organ can be useful but it is not essential. Your liver will still produce bile to digest food.

Why do I have gallstones?

It is thought that gallstones 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. You are more at risk of developing gallstones if you are:

• overweight 
• female – women are two to three times more likely to be affected by gallstone disease than men
• 40 or over – most cases of gallstone disease first develop in people aged 40 or above
• a mother – women who have had multiple pregnancies have an increased risk of getting gallstone disease. It is thought that the hormonal changes that occur during pregnancy can increase cholesterol levels.

Gallstones can be quite large and hard, causing significant symptoms.

Who is affected

Gallstones are very common. It is estimated that, in England, around one in 10 of the adult population has gallstones. However, in most cases, they do not cause symptoms. There is a one in 50 (2%) chance of gallstones causing symptoms. Most people only experience biliary colic, but a minority of people go on to develop more troublesome symptoms or a complication.

Complications

Cancer of the gallbladder is a rare but serious complication of gallstones. An estimated 670 cases of gallbladder cancer are diagnosed in the UK each year. Another rare but serious complication of gallstones is known as gallstone ileus. This is where the bowel becomes obstructed by a gallstone. This can cause symptoms such as vomiting and constipation.

Outlook

Most cases of gallstone disease are easily treated. Very severe cases can be life-threatening, especially in people who are already in a poor state of health, but deaths are now rare in England. It is estimated that the chance of dying from gallstone disease is less than one in 175.

Causes of gallstones 

It is thought that gallstones develop because of an imbalance in the chemical make-up of bile inside the gallbladder. Bile is a liquid that is produced by the liver to help digest fats. It is still unclear what leads to this imbalance, but it is known that gallstones can form in two ways:

• there are unusually high levels of cholesterol inside the gallbladder and the excess cholesterol gradually solidifies to form a stone; four out of five gallstones are made up of cholesterol
• there are unusually high levels of bilirubin inside the gallbladder; bilirubin is a waste product produced when red blood cells are broken down – the remaining one out of five gallstones is made up of bilirubin.

Who is at risk?

Gallstones are more common in the following groups:

• women, particularly those that have had multiple pregnancies
• obese people – people who are overweight with a body mass index (BMI) of 30 or above
• people who are 40 years of age or over (the older you are, the more likely you are to develop gallstones)
• people with cirrhosis (scarring of the liver)
• people with the digestive disorders Crohn’s disease and irritable bowel syndrome (IBS)
• people with a family history of gallstones (around a third of people with gallstones have a close family member who has also had gallstones)
• people who have recently lost weight, either as a result of dieting or weight-loss surgery such as gastric banding
• people who are taking a medication called ceftriaxone, which is an antibiotic used to treat a range of infections, including pneumonia, meningitis and gonorrhoea.

Women who are taking the combined oral contraceptive pill or undergoing high-dose oestrogen therapy (which is sometimes used to treat osteoporosis, breast cancer and the menopause) also have an increased risk of developing gallstones.

Other possible risk factors

Having type 2 diabetes and a lack of exercise are also possible risk factors.  However, they have not yet been conclusively proven to increase the risk of developing gallbladder problems. 

Symptoms of gallstones 

The most common symptom of gallstone disease is biliary colic, which is caused when a gallstone temporarily blocks one of the bile ducts. Bile ducts are tube-like structures that carry bile from the liver to the gallbladder and then into the digestive system.

Biliary colic

Biliary colic is a sudden, intense pain that usually lasts for over an hour (although sometimes it can last just a few minutes). The pain can be felt in:

• the centre of your abdomen, below your breastbone and above your bellybutton
• the upper right of your abdomen, with the pain travelling towards your shoulder blade

The pain is constant, dull and is not relieved when you go to the toilet, pass wind or are sick.

The pain can be triggered by eating fatty foods and it may wake you up during the night. Biliary colic usually happens infrequently. After an episode of pain, it may be several weeks or months before you experience another episode. In addition to the pain associated with biliary colic, a number of people also experience:

• feeling sick
• being sick
• excessive sweating.

Doctors sometimes refer to biliary colic as uncomplicated gallstone disease.

The progression of symptoms

If you do develop symptoms of biliary colic it does not necessarily mean you will go on to develop a more serious form of gallbladder disease such as acute cholecystitis or acute pancreatitis. It is estimated that only around one in 20 people with biliary colic will then go on to develop more severe symptoms.

Doctors use three categories when describing gallstone disease:

• gallstones without symptoms – asymptomatic gallstone disease
• gallstones that cause episodes of abdominal pain (biliary colic) – uncomplicated gallstone disease
• severe forms of gallstone disease – known as complicated gallstone disease.

When to seek medical advice

If you think you may be experiencing episodes of biliary colic you should make an appointment with your family doctor. You should seek immediate medical advice if you experience any of the following symptoms:

• jaundice – yellowing of the skin and eyes
• abdominal pain that lasts longer than eight hours
• a high temperature combined with chills
• abdominal pain so intense that you cannot find a position to relieve it.

Diagnosing gallstones 

Gallstones are often discovered by chance during investigations of unrelated conditions. They are commonly detected during:

• blood tests – tests that show abnormal liver function may indicate gallstones
• ultrasound scans – where high frequency sound waves are used to create an image of part of the inside of the body
• imaging scans, such as CT and MRI scans – see below.

Occasionally, gallstones are detected during abdominal X-rays; only gallstones containing a lot of calcium show up clearly on X-ray. If you are experiencing symptoms that could be associated with gallstone disease, your doctor will want to know whether this is due to biliary colic (which does not require urgent treatment) or a more serious form of gallbladder disease, such as inflammation of your gallbladder (which may require urgent treatment).

They will ask you about your symptoms and may also carry out a simple test known as the Murphy’s sign test. You breathe in and your doctor gently taps your abdomen near the location of your gallbladder. If the tapping causes pain, it usually indicates that your gallbladder is inflamed.

Gallstones can be confirmed using an ultrasound scan. You may also have blood taken for a liver function test. This is a type of blood test that assesses the state of your liver. If gallstones have moved into your bile duct, the normal functioning of your liver will be disrupted. If your symptoms suggest that you have biliary colic then you will be referred for a routine ultrasound.

If your symptoms suggest that you have a more severe form of gallbladder disease then you may be admitted to hospital on the same day for an ultrasound scan or another investigation.

Cholangiography

When gallstones are diagnosed, a procedure called a cholangiography will give further information about the condition of your gallbladder. A cholangiography uses a dye that shows up on X-rays. The dye is inserted into your bile ducts either at operation (operative cholangiogram) or using a flexible, fibre-optic camera (endoscope). This procedure is called endoscopic retrograde cholangiopancreatolography (ERCP).

After the dye has been introduced, X-ray images are taken. They will 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).

MRI scans

A magnetic resonance imaging (MRI) scan, which uses strong magnetic fields to produce a detailed image of the inside of the body. MRI scanners tend to be used if a bile duct stone is suspected.

CT scan

X-rays are taken from many different angles and the images processed to show the body in slices. This is known as a computer topography (CT) scan. This can show up gallstones as an incidental finding or may be used to investigate a complication of gallstones such as acute pancreatitis. This test is often done as an emergency to diagnose severe abdominal pain.

Preventing gallstones 

You cannot change some of the things that make you more likely to develop gallstones, for example your age and your gender. However, from the limited evidence available, changes to your diet and losing weight (if you are overweight) may help prevent gallstones.

Diet

Due to the role that cholesterol appears to play in the formation of gallstones, it is advisable to avoid eating fatty foods with a high cholesterol content. Foods that are high in cholesterol include:

• meat pies
• sausages and fatty cuts of meat
• butter and lard
• cakes and biscuits.

A low-fat, high-fibre diet is recommended. This includes plenty of fresh fruit and vegetables (at least five portions a day) and wholegrains. There is also evidence that regularly eating nuts, such as peanuts or cashews, can help reduce your risk of developing gallstones. Cutting down your drinking to no more than 3-4 units a day for men and 2-3 units a day for women may also reduce your risk.

Losing weight

Being overweight, and particularly being obese, increases the amount of cholesterol in your bile, which, in turn, increases your risk of developing gallstones. You should, therefore, control your weight by eating a healthy diet and taking plenty of regular exercise. However, avoid low-calorie, rapid weight loss diets. There is evidence that they can disrupt your bile chemistry and increase your risk of developing gallstones. A more gradual weight loss plan is recommended.

Treating gallstones 

Your treatment plan will depend on how the symptoms are affecting your daily life. In cases of gallstones without symptoms, a policy of ‘active monitoring’ is often recommended. This means you will receive no immediate treatment, but you should let your doctor 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 getting complications. These conditions include:

• scarring of the liver (cirrhosis)
• high blood pressure inside the liver – this is known as portal hypertension and can often arise as a complication of alcoholic liver disease
• diabetes.

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 biliary colic. Treatment will depend on how the symptoms are affecting your daily activities. If your symptoms are mild and infrequent, you may be prescribed painkillers to control further episodes.

Surgery to remove your gallbladder (laparoscopic cholecystectomy) will usually be recommended if your symptoms are more severe and occur frequently, and lead to a reduction in your quality of life.

Laparoscopic cholecystectomy

A cholecystectomy is surgery to remove your gallbladder, and laparoscopic is a type of keyhole surgery. Three or four small cuts (each about 1cm or less) are made in your abdomen. One cut will be by the belly button and the others will be on the right side of your abdomen.

Your abdomen is inflated using carbon dioxide gas. This is harmless and makes it easier for surgeon to see your organs. A laparoscope (a 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. Using special surgical instruments, your surgeon will then remove your gallbladder.

Sometimes, if there is a risk of gallstones in the bile duct, an X-ray of the bile duct (operative cholangiogram) is also taken during the operation. If gallstones are found, they can sometimes be removed during keyhole surgery. If the operation cannot be done this way or an unexpected complication occurs, it may have to be converted to open cholecystectomy (see below). Bile duct stones can also be removed before or after your operation with a special endoscopy called an ERCP, or endoscopic retrograde cholangiopancreatolography.

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.

The operation takes 60 to 90 minutes and is usually carried out as a day case, so you can go home that day.

Schematic diagram showing how laparoscopic (keyhole) cholecystectomy is performed.

Single-incision laparoscopic cholecystectomy

Single-incision laparoscopic cholecystectomy is a newer type of keyhole surgery used to remove the gallbladder. Only one small cut is made, which has the cosmetic advantage of leaving a barely visible scar.

However single-incision laparoscopic cholecystectomies haven’t been carried out as often as traditional laparoscopic cholecystectomies, so it is still very much an evolving field of medicine. Access to this type of surgery is also limited because it needs an experienced surgeon with specialist training.

Open cholecystectomy

In some circumstances, a laparoscopic cholecystectomy may not be recommended. This may be due to technical reasons, safety concerns or if there is a stone in the bile duct that cannot be removed another way. A laparoscopic cholecystectomy may not be recommended if you:

• are in the third trimester (the last three months) of pregnancy
• are morbidly obese – extremely overweight with a body mass index of 40 or above
• have cirrhosis (scarring of the liver)
• have a condition that affects your blood’s ability to clot (thicken), such as haemophilia.

In these circumstances, an open cholecystectomy may be recommended. During this procedure, a 10-15 cm (4-6 inch) incision is made in your abdomen underneath the ribs. This will result in a scarring. Open surgery is just as effective as laparoscopic surgery, but it does have a longer recovery time. Most people take about six weeks to recover from the effects of an open cholecystectomy.

Schematic diagram showing how the open and laparoscopic cholecystecomies are performed.

Endoscopic retrograde cholangiopancreatolography (ERCP)

Endoscopic retrograde cholangiopancreatolography (ERCP) is a procedure that aims to remove bile duct stones. In some patients this is the only treatment required. However, the gallbladder and stones in the gallbladder remain. An ERCP is usually carried out under sedation, which means that you will be awake throughout the procedure but will not experience any pain.

ERCP is similar to a diagnostic cholangiography, except that an electrically heated wire is passed through the endoscope and is used to widen the opening to your bile duct. The  bile duct stones are then removed or left to pass into your intestine. Sometimes a small narrow tube called a stent is placed in the bile duct to help the bile and stones pass.

Alternative treatments

A number of alternative treatments have been tried but they are not very successful, have problems of their own and gallstones can reoccur very quickly once treatment is stopped.

Tablets to dissolve the gallstones (ursodeoxycholic acid)

A few patients' small non-calcified gallstones made of cholesterol in a normally functioning gallbladder can be dissolved by taking a medication called ursodeoxycholic acid for up to two years. To make treatment more effective, you may be advised to eat a low-cholesterol diet.

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 is not 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. Once the treatment is stopped the gallstones usually reoccur.

Ursodeoxycholic acid can also be prescribed as a precaution against gallstones if it is thought that you are at risk of developing them. For example, you may be prescribed ursodeoxycholic acid if you have recently had weight loss surgery.

Lithotripsy

Lithotripsy is a method of concentrating ultrasonic shock waves on to the gallstones to break them up into tiny pieces. Once the gallstones have been broken up, they can pass out of your body in your stools (poo). Unfortunately, in some patients the gallstones remain and grow, and in others the debris causes acute pancreatitis or jaundice.

It is rarely used when other treatments are possible as there can be up to a 50% chance of symptoms returning within five years of treatment. The healthcare professional carrying out the lithotripsy procedure will first use an ultrasound scan to determine the location of the gallstones. They will press a sensor against your abdomen, next to the gallstones, which will then deliver the ultrasonic waves on to the gallstones.

Complications of gallstones 

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 irritated 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 will 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 is a higher risk of it being converted to an open procedure.

Sometimes a bad infection can lead to a gallbladder abscess (empyema of the gallbladder). Antibiotics alone do not always treat these and they may need to be drained. Occasionally a severely inflamed gallbladder can tear, leading to peritonitis. This will need an emergency operation.

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 faeces (stools or ‘poo’)
• itching.

Sometimes the stone passes from the bile duct on its own. If it doesn’t, the stone needs to be removed. Infection of the bile ducts (acute cholangitis). If the bile ducts become blocked, they are 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 will help treat the infection, but it is also important to help the bile from the liver to drain with an endoscopic retrograde cholangiopancreatolography (ERCP).

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.

Cancer of the gallbladder

Cancer of the gallbladder is a rare but serious complication of gallstones. An estimated 670 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 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 are not 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. There are around 550 hospital admissions for gallstone ileus each year in England.

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 is not treated, there is a risk that the bowel could split open (rupture). This could cause internal bleeding and widespread infection. If you suspect that you have an obstructed bowel, contact your doctor as soon as possible. Surgery is usually required to remove the gallstone and unblock the bowel. The type of surgery that you will receive depends on where in the bowel the obstruction has occurred.  

Source: NHS Choices.