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What are gallstones?
Gallstones form in your gallbladder, the small, pear-shaped organ where your body stores bile. They are pebble-like pieces of concentrated bile materials. Bile fluid contains cholesterol, bilirubin, bile salts and lecithin. Gallstones are usually made up of cholesterol or bilirubin that collect at the bottom of your gallbladder until they harden into “stones.”
Gallstones can be as small as a grain of sand or as big as a golf ball. They grow gradually, as bile continues to wash over them and they collect extra materials. Actually, it’s the smaller stones that are more likely to cause trouble. That’s because smaller stones can travel, while bigger ones tend to stay put. Gallstones that travel may get stuck somewhere and create a blockage.
What is cholelithiasis?
Cholelithiasis is the condition of having gallstones. Many people have cholelithiasis and don’t know it. Gallstones won’t necessarily cause any problems for you. If they don’t, you can leave them alone. But gallstones can sometimes cause problems by creating a blockage. This will cause pain and inflammation in your organs. If it goes untreated, it can cause serious complications.
How common are gallstones?
Gallstones are common in developed countries, affecting about 10% of adults and 20% of those over the age of 65. Only 20% of people diagnosed with gallstones will need treatment.
How does having gallstones (cholelithiasis) affect me?
Your gallbladder is part of your biliary system. It belongs to a network of organs that pass bile between each other. These organs are connected by a series of pipelines called bile ducts. Bile travels through the bile ducts from your liver to your gallbladder, and from your gallbladder to your small intestine. Your pancreas also uses the bile ducts to deliver its own digestive juices.
A gallstone that travels to the mouth of your gallbladder can obstruct the flow of bile in or out. A gallstone that makes its way out of your gallbladder and into the bile ducts could block the flow of bile through the ducts. This will cause bile to back up into the nearby organs. When bile backs up, it builds pressure and pain in your organs and bile ducts and causes inflammation.
This can lead to a variety of complications, including:
- Gallbladder disease. Gallstones are the most common cause of gallbladder diseases. When they get stuck, they cause bile to back up into your gallbladder, causing inflammation. This can do long-term damage to your gallbladder over time, scarring the tissues and stopping it from functioning. The stalled flow of bile also makes infections in your gallbladder more likely.
- Liver disease. A blockage anywhere in the biliary system can cause bile to back up into your liver. This will cause inflammation in your liver, leading to an increased risk of infection and long-term scarring over time (cirrhosis). If your liver stops functioning well, your whole biliary system breaks down. You can live without a gallbladder but not without a liver.
- Gallstone pancreatitis. A gallstone that blocks the pancreatic duct will cause inflammation in your pancreas. As with your other organs, temporary inflammation causes pain, and chronic inflammation causes long-term damage that can stop your organ from functioning.
- Cholangitis. Inflammation in your bile ducts can lead to infections in the short term and scarring in the long term. Scarring in your bile ducts causes them to narrow, which restricts the flow of bile. This can cause long-term bile-flow problems even after the blockage has been removed.
- Jaundice. Backed-up bile will leak into your bloodstream, making you sick. Bile carries toxins that your liver has filtered from your body. The bilirubin content has a yellow color, which will be visible in the whites of your eyes.
- Malabsorption. If bile can’t travel to your small intestine as intended, you might have difficulty breaking down and absorbing nutrients from your food. Bile is particularly important for breaking down fats and for absorbing fat-soluble vitamins in your small intestine.
Symptoms and Causes
What is the main cause of gallstones?
As much as 75% of the gallstones healthcare providers discover are made up of excess cholesterol. So, we could say that having excess cholesterol in your blood is the leading cause of gallstones. You might have extra cholesterol for a variety of reasons. Some of the most common reasons include metabolic disorders, such as obesity and diabetes.
High blood cholesterol leads to higher cholesterol content in your bile. Your liver filters cholesterol from your blood and deposits it in bile as a waste product before sending the bile to your gallbladder. Chemicals in bile (lecithin and bile salts) are supposed to dissolve cholesterol. But if there’s too much of it, these chemicals might not be up to the task.
What else causes cholelithiasis?
Other factors that contribute to gallstones include:
- Excess bilirubin: About 25% of gallstones are made up of excess bilirubin instead of cholesterol. Bilirubin is a byproduct that’s produced when your liver breaks down red blood cells. Certain medical disorders can cause your liver to produce extra bilirubin while doing its job. Some of these include infections, blood disorders and liver disease.
- Gallbladder stasis: Your small intestine signals to your gallbladder to send bile when it has fats to digest. When your gallbladder is healthy, it contracts to efficiently move bile out when necessary. But if your gallbladder doesn’t contract well enough, some bile may be left behind. This bile gradually concentrates into a kind of sludge at the bottom of your gallbladder, which then crystallizes.
Who gets gallstones?
Anyone can get gallstones, including children, but they are more common after the age of 40. That’s because gallstones grow very gradually. It may take 10 to 20 years for gallstones to grow large enough to cause an obstruction. They are also more common in people assigned female at birth than in those assigned male at birth, by a ratio of 3:1. This is due to the effects of female hormones.
Other common risk factors include:
- Native American or Mexican descent. These peoples share a genetic profile of higher cholesterol levels.
- Metabolic syndrome. A constellation of metabolic risk factors, including overweight, high blood triglycerides and insulin resistance, contribute to the risk of cholesterol gallstones.
Why are women more at risk of developing gallstones?
Estrogen increases cholesterol, and progesterone slows down gallbladder contractions. Both hormones are especially high during certain periods in your reproductive life, such as menstruation and pregnancy. When hormone levels begin to drop in menopause, many people use hormone therapy (HT) to replace them, which elevates them again.
Women and people assigned female at birth are also more likely to gain and lose body fat more frequently. Excessive body fat can translate to extra cholesterol in your blood. Having obesity increases estrogen. On the other hand, rapid weight loss has a similar effect to weight gain. When you lose a lot of body fat at once, it sends an unusually large load of cholesterol to your liver for processing, which ends up in your bile.
What are the first signs of having gallstones?
You won’t notice your gallstones unless one gets stuck somewhere and causes a blockage. When that happens, the most typical symptom is a type of abdominal pain, in the right upper quadrant of your abdomen, called biliary colic. It occurs in episodes that last for one to several hours, usually after a large or rich meal. That’s when your gallbladder contracts to send bile to your small intestine for digestion.
If you have occasional episodes of biliary colic, it means that a gallstone is causing a partial blockage, but you can’t feel it until your gallbladder contracts. The contraction forces pressure through your bile ducts and causes that pressure to build up inside when it meets resistance. This is a warning sign. When the blockage becomes more severe, your pain will too.
What is gallstone pain like?
Gallbladder pain most often occurs in the upper right side of your abdomen, under your ribcage, where your gallbladder is located. But sometimes it feels more vaguely located in your abdomen. The pain can also radiate somewhere else, most often to your right arm or shoulder blade. It starts as an ache and then steadily increases in intensity over the first hour before receding again.
Despite the name, biliary colic is not “colicky pain,” which is sharp and comes in waves. It has a slow and steady arc, and it’s usually dull but severe. It may bring you to the emergency room for relief. You may also notice that your upper right abdomen is tender to the touch. Biliary colic is often accompanied by nausea and vomiting. It’s also called a “gallbladder attack.”
Do gallstones cause other symptoms?
When a gallstone causes a persistent blockage or an infection, you’ll have symptoms of acute inflammation. This may include:
- Constant pain.
- Fever and chills.
- Heart rate accelerations.
You may also begin to show symptoms of bile accumulating in your bloodstream, such as:
- Sunken eyes.
- Dark-colored pee.
Diagnosis and Tests
How are gallstones diagnosed?
If you’re experiencing symptoms of biliary colic, your healthcare provider will investigate with blood tests and imaging tests. Blood tests can detect inflammation, infection or jaundice. They can also give your healthcare provider clues about which organs are being affected. Imaging tests will help locate the source of the blockage. They will usually start with an ultrasound.
What tests are used to diagnose cholelithiasis?
Ultrasound: An abdominal ultrasound is a simple and noninvasive test that requires no preparation or medication. It’s usually all that’s needed to locate gallstones. However, it doesn’t visualize the common bile duct very well. If your healthcare provider suspects there’s a gallstone hidden in there, they might need to use another type of imaging test to find it.
MRCP: Magnetic resonance cholangiopancreatography (MRCP) is a type of MRI that specifically visualizes the bile ducts. It’s non-invasive and creates very clear images of your biliary system, including the common bile duct. Your provider might use this test first to find a suspected gallstone there. But if they’re already pretty sure it’s there, they might skip it and go straight to an ERCP.
ERCP: ERCP stands for endoscopic retrograde cholangiopancreatography. This test is a little more invasive, but it’s a useful one for finding gallstones because it can also be used to remove them from the ducts if they are stuck there. It uses a combination of X-rays and endoscopy, which means passing a tiny camera on the end of a long tube down your throat and into your upper GI tract. (You’ll have medication to make this easier.)
When the camera (endoscope) reaches the top of your small intestine, your healthcare provider will slide another, smaller tube into the first one to reach farther down into your bile ducts. They will inject a special dye through the tube and then take video X-rays (fluoroscopy) as the dye travels through the ducts. They can insert tools through the tube to remove the stones they find.
_Endoscopic retrograde cholangiopancreatography (ERCP) can diagnose and sometimes treat gallstones.
Endoscopic ultrasound passes through the mouth to the common bile duct and gall bladder.
Management and Treatment
Does cholelithiasis require surgery?
Most people with gallstones will never need treatment. But if your gallstones cause problems, your healthcare provider will want to remove them. Usually, they will want to remove all of your gallstones, even if only one of them is currently causing trouble. If a blockage happens once, it’s likely to happen again. The risk isn’t worth waiting around for.
Since there’s no way to access the gallstones inside your gallbladder without removing it, the standard treatment for problematic gallstones is to remove the gallbladder entirely. This is a minor surgery, and you can live well without a gallbladder. If you have gallstones in your bile ducts, your healthcare provider will have to remove those separately as well.
Can gallstones go away without surgery?
Gallstones in your bile ducts that aren’t stuck can successfully pass through them and into your intestines. You can pass them out through your poop. That's a lucky scenario, but in general, you don’t want to risk having gallstones in your bile ducts in the first place. If they don’t pass all the way out of you, they will only grow bigger over time.
There are some medications that can help to dissolve smaller gallstones. These take many months to work, so they aren’t the most practical option for people experiencing symptoms. But they offer an alternative for people who may not be in a safe health condition for surgery. They may also be practical for people who have gallstones but don’t have symptoms yet.
How are gallstones removed?
There are a few different ways to remove gallstones.
Gallstones in your bile ducts are removed by endoscopy (ERCP). This doesn’t require any incisions. The gallstones come out through the long tube that’s been passed down your throat. Gallstones in your gallbladder are removed by removing the gallbladder (cholecystectomy). This can usually be done by laparoscopy, a minimally-invasive surgery technique.
A laparoscopic cholecystectomy uses small, “keyhole incisions” in your abdomen to operate with the aid of a small camera called a laparoscope. Your surgeon inserts the laparoscope through one keyhole and removes your gallbladder through another. Smaller incisions make for less post-operative pain and a faster recovery time than conventional, “open” surgery.
Some people may have more complicated conditions that require open surgery to manage. If you have open surgery, you’ll have a longer hospital stay afterward and a longer recovery at home for your larger incision. Some laparoscopic cholecystectomies may need to convert to open surgery if your surgeon runs into complications during the procedure.
What are the complications or side effects of gallstone surgery?
After laparoscopic surgery, you may have some abdominal gas and gas pain. You can have this after ERCP too. Both methods pump gas into your organs to expand them and help them show up better in images. It will pass in a day or so. Complications during the operation are rare but include bleeding, infection, and injury to nearby organs.
How long is the recovery from gallstone surgery?
If you have a laparoscopic cholecystectomy, you can be home within 24 hours. You can recover in about two weeks. If you have open surgery, you’ll need to stay in the hospital for three to five days afterward. Your recovery at home will be six to eight weeks. Your digestive system may take two to eight weeks to adjust after the operation.
What happens when you don’t have a gallbladder anymore?
Your digestive system can still function without a gallbladder. Your gallbladder is mostly a holding place for the bile your liver makes. It delivers bile to your small intestine to help with digestion. When your surgeon removes your gallbladder, they’ll redirect your bile ducts so that bile can flow directly from your liver to your small intestine.
Will I need to change my diet after gallstone surgery?
Your digestive system may take some weeks to adjust to the lack of a gallbladder. Some people may experience temporary indigestion or diarrhea during the transition period. Your healthcare provider will advise you not to eat anything too rich or fatty while you recover. Most people can return to a normal (but reasonably healthy) diet after a few weeks.
Can diet help to prevent gallstones?
You can reduce your risk of cholesterol gallstones, which are the most common type, by reducing cholesterol in your diet. Here are some quick tips:
- Limit fried and fast foods. These foods are usually fried in saturated fats, which promote LDL cholesterol (the “bad” type). If you cook with oil, choose plant oils instead of animal fats.
- Replace red meat with fish. Red meat is high in saturated fats, while fish is high in omega-3 fatty acids, which promote HDL cholesterol (the “good” type). The good type helps balance the bad type.
- Eat more plants. High-fiber fruits, vegetables and whole grains help to clear out excess cholesterol from your body. Eating more plants can also help you keep your overall weight down.
- Lose weight gradually. Dieting to lose weight can help reduce the cholesterol content in your blood. But it’s better to lose weight at a slow, steady pace of one to two pounds a week. Rapid weight loss can encourage gallstones.
Outlook / Prognosis
What is my prognosis if I have gallstones (cholelithiasis)?
If you have gallstones but they haven’t caused you any problems yet, they probably never will. About 2% of asymptomatic gallstones become symptomatic each year. Once they begin to cause symptoms, they are likely to keep doing so. About 2% of people with symptomatic gallstones develop complications each year, such as acute inflammation and infection.
Cholecystectomy is a definitive treatment for most gallstones, and most people recover quickly and completely from it. Some people may still have gallstones show up in their bile ducts again afterward. These can be treated by an endoscope. If you use medicine to dissolve your gallstones, this works about 75% of the time, but the gallstones will often come back again.
When should I seek care for gallstones?
If you experience anything like biliary colic, seek immediate attention. Biliary pain is dull and persistent, growing for about 20 minutes and lasting for one to several hours. It’s usually in the upper right quadrant of your abdomen, but sometimes it’s referred elsewhere. It’s often accompanied by nausea and vomiting, but vomiting doesn’t relieve it.
A note from Cleveland Clinic
Gallstones are common, and most people will never be bothered by them. If they stay put in your gallbladder, you’ll probably never know they’re there. But once they begin to move, they become dangerous. These tiny, pebble-like pieces can do a lot of damage when they get into the tight spaces of your delicate biliary system.
A gallbladder attack can be intense and scary, especially if you didn’t know you had gallstones to begin with. It may be alarming to find out that the recommended treatment is surgery. But laparoscopic gallbladder removal is a common procedure with an excellent prognosis. Your whole ordeal may be over within hours of your first symptoms.
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