What are gallstones?
Gallstones are stone-like objects that develop in the gallbladder or bile ducts (the pipe-like system within the liver). Gallstones can range dramatically in size, from tiny grains of sand to golf ball-sized objects. Interestingly, small stones can often cause the most trouble. These are stones that can leave the gallbladder and get stuck. Larger stones tend to remain quietly in the gallbladder. It is important to know that many people who have gallstones are never bothered by them and may not know the stones are even there. In these cases, no treatment is needed.
What are gallstones made of?
Gallstones are made up of hardened materials in your body. Typically, there are two types:
- Cholesterol: Made up of fatty substances in the blood, cholesterol is found throughout the body. These are the most common type of gallstones.
- Pigment Stones (mainly made of bilirubin): This substance is created when red blood cells break down in the liver. Too much bilirubin can actually leak into the bloodstream and cause the skin and eyes to turn yellow (jaundice).
Gallstones that are made up of cholesterol tend to be greenish in color. It is more common to have gallstones made of cholesterol than other types of stone.
Where do gallstones develop?
Gallstones are most commonly found in the gallbladder, as cholesterol stones. Gallstones can also travel from the gallbladder to the common bile duct, which is the largest of the ducts (pipes) in the liver.
Common bile duct stones are much less common than gallstones. Stones that find their way into the common bile duct can create more serious medical situations than just gallstones that remain in the gallbladder. Common bile duct stones can block the common bile duct, resulting in a serious infection called cholangitis. These stones can also cause pancreatitis, a painful condition caused by inflammation of the pancreas. Stones in the common bile duct can be removed without surgery by using a scope. Removal of the gallbladder requires surgery, which is typically done laparoscopically (a minimally invasive surgical procedure).
Illustration showing the gallstones and organs around the gallbladder.
What is the gallbladder?
The gallbladder is a small organ tucked up under the liver, on the right side of your body. It is shaped like a swollen pea pod. The gallbladder’s job is to store and dispense bile—a fluid that helps digest fats in the food you eat. Similarly to a pea pod, the gallbladder is green. This is due to the bile inside the gallbladder. Bile is a mixture of cholesterol, bilirubin, bile salts and lecithin.
The gallbladder is connected to other parts of the digestive system through a series of ducts, or tunnels. These ducts help to carry bile and aid in the entire process of breaking down food. Ultimately, the bile finds its way into the common bile duct, where it passes through a special sphincter (a valve made of muscle), into the small intestine. Once there, the bile can mix directly with food that’s waiting to be digested. The common bile duct then empties bile into the duodenum, the first portion of the very lengthy small intestine.
Not all bile travels directly from the liver into the duodenum. Another portion of bile moves from the liver into the gallbladder through a special duct called the cystic duct. The gallbladder stores bile, which is available to be used for digestion on very short notice. If a fatty meal is eaten, then the gallbladder is signaled to contract and to squeeze some stored bile into the common bile duct where it’s passed into the small intestine to mix with food. All bile ends up in the small intestine, where it helps digest food.
What is bile and what is it used for?
Produced in the liver, bile is a combination of cholesterol, bilirubin, bile salts and lecithin. This solution helps break down fat during the digestion process. Bile is either released directly to the small intestine from the hepatic duct (coming straight from the liver) or from the bile ducts after being stored in the gallbladder. The entire system of ducts is called the biliary system. Bile is an important part of digestion and exits the body with your feces.
Symptoms and Causes
Why do gallstones develop?
Gallstones can develop for several reasons, including:
- Forming when there is a critical concentration of cholesterol or bilirubin in the bile.
- Developing if the gallbladder is lazy and does not completely empty itself of bile.
- Occurring in people with other conditions, like:
- Cirrhosis of the liver.
- Blood disorders.
- During pregnancy.
- When you rapidly lose weight.
What are the symptoms of gallstones?
The symptoms of gallstones can vary based on the size of the gallstone. Most gallstones do not cause any symptoms at all. These gallstones are known as silent stones and require no treatment.When the gallstones cause symptoms, they may include:
- Pain in the upper mid abdomen or upper right abdomen.
- Associated pain in the right shoulder.
- Chest pain.
- Nausea and vomiting.
- Repeated similar episodes.
- Jaundice (a yellow tint to the skin and eyes).
Pain is the main symptom most people experience with gallstones. This pain is steady and can last from around 15 minutes to several hours. The episodes, which can be severe, generally subside after one to three hours or so. People who have these painful attacks, while uncomfortable, are not in any medical jeopardy. Gallstones can cause acute cholecystitis, which is a more serious condition when the gallbladder is actually inflamed. This happens if a stone blocks off the cystic duct, which increases the pressure within the gallbladder. This condition may require antibiotics, hospitalization and even urgent surgery. Stones that pass out of the gallbladder and into the common bile duct can cause a complete blockage of the duct with jaundice, infection and pancreatitis.You may feel pain in several places, including:
- Upper part of the abdomen, on the right side.
- Between the shoulder blades.
- Under the right shoulder.
When people experience pain with gallstones, it is sometimes referred to as a gallbladder attack or biliary colic.There are two special conditions that could mimic gallstone symptoms. First, some gallbladders contain a thick sludge, which has not formed into actual stones. Sometimes sludge is felt to cause symptoms similar to actual gallstone pain. Secondly, there is an uncommon condition called acalculous cholecystitis, when the gallbladder becomes inflamed, but no stones are present. This is generally treated by surgical removal of the gallbladder.
Who is at risk for gallstones?
You may have an increased risk for developing gallstones if you:
- Are a woman.
- Are over the age of 40.
- Have a family history of gallstones (members of your family have had gallstones).
- Are overweight.
- Have lost a large amount of weight over a short amount of time.
- Have diabetes.
- Have Crohn’s disease.
- Eat a diet that is high in fat and cholesterol.
- Take drugs that lower cholesterol.
- Take various medicines including oral contraceptives.
- Have certain blood disorders.
- Are of Native American or Mexican descent.
Does my diet or weight place me at risk for gallstones?
People who are overweight or planning to lose weight –either through a planned diet program or a surgery—are actually at an increased risk of developing gallstones. The risk is higher for several reasons.
- People who are overweight may have diets that are high in cholesterol. Your bile has cholesterol in it already, but if your diet has excessive amounts of cholesterol, there is a higher chance it will collect in your bile and create a cholesterol gallstone.
- Rapid weight loss is also a concern. The gallbladder is a part of the digestive process. It holds bile to the side like a storage tank. Then the gallbladder releases the bile through the ducts and into the intestine to help break down food. If you go on a diet plan that significantly reduces your calorie intake or you have a weight loss surgery, your liver secretes extra cholesterol into the bile. The gallbladder can sometimes be ‘lazy’ and not able to contract vigorously, which also leads to gallstone formation. Patients who are undergoing a gastric bypass or other surgical procedure that will lead to rapid weight loss are at risk of gallstone formation. For this reason, surgeons may remove the gallbladder prophylactically (a preventive measure) at the time of the weight loss surgery.
If you are considering a weight loss program or surgery, it is important to discuss your risks with a doctor. This could be especially important if you have had stones in the past. It is common for gallstones to happen more than once.
Can children get gallstones?
Gallstones can happen to both children and adults. It is most common to see gallstones in middle-aged adults. However, adults are not the only ones who experience gallstones. One challenge with gallstones in children is identifying symptoms. Young children may have difficulty expressing where the pain is located. If you child has any unusual symptoms or abdominal pain, call your doctor.
Diagnosis and Tests
How are gallstones diagnosed?
The most commonly used test to detect gallstones is an ultrasound. Ultrasound is a painless and accurate procedure that transmits high-frequency sound waves through body tissues. The echoes are recorded and transformed into video or photographic images of the internal structures of the body. While no test is 100%, this is a very accurate test for diagnosing gallstones. There are other radiology tests that are sometimes used, but ultrasound is the main tool for diagnosing gallbladder disease.In general, ultrasound does not visualize the common bile duct well. Though stones in this duct aren’t as common, they can happen. If they are suspected, the following tests may be done:
Endoscopic retrograde cholangiopancreatography (ERCP): This is both a test and a possible treatment for common bile duct stones. When used as a test, an endoscope—a flexible tube with a light and a camera attached—is inserted into the patient's mouth, down the throat, and into the stomach and small intestine. A dye is injected to allow the bile ducts to stand out. If there are gallstones in the bile duct, they can be removed by the endoscope. This scope cannot remove stones contained within the gallbladder.
Illustration showing the flexible tube for the ERCP can diagnose and sometimes treat gallstones.
Magnetic resonance cholangiopancreatography (MRCP): In MRCP, the bile ducts are examined with magnetic resonance imaging (MRI), a test that uses a large magnet, radio waves, and a computer to produce very clear images of parts of the body. Unlike ERCP, MRCP can only diagnose common bile duct stones. It cannot remove them. However, MRCP’s advantage over ERCP is that it is the safer alternative, so often physicians will opt for MRCP initially.Endoscopic ultrasound (EUS): This procedure combines endoscopy with ultrasound (there’s a probe at the tip of the scope). Like ERCP, this scope is passed through the mouth and advanced to the common bile duct and gallbladder region. It visualizes the common bile duct well. Similarly to MRCP, gallstones are identified but not removed during this procedure. If common bile duct stones are demonstrated by EUS (or MRCP), then an ERCP will generally follow to remove them.
Illustration showing how the scope of the can go into the body to view the gallstones.
Management and Treatment
Incision locations for a laproscopic cholecystectomy
How are gallstones treated?
Silent stones are not treated and should be left alone. Most people who have gallstones are in this category.If you have symptoms, such as pain, you will probably need to be treated. The most common treatment for gallstones is to remove the gallbladder surgically. Removal of the gallbladder is called a cholecystectomy. In the majority of cases (90%), this surgery can be performed laparoscopically, a minimally invasive technique that results in less post-operative pain and a faster recovery than conventional cholecystectomy.Gallstones that are found in the bile ducts may need to be removed even if there are no symptoms. This procedure is commonly done with the endoscopic retrograde cholangiopancreatography (ERCP) procedure.
What is a laparoscopic cholecystectomy?
Laparoscopic cholecystectomy is known as a minimally invasive procedure because it uses several small incisions instead of one large one. A laparoscope is a narrow tube with a camera. This surgical tool is inserted through one incision. The camera allows your doctor to see your gallbladder on a TV screen. Your gallbladder is then removed through another small incision.
What happens if a laparoscopic cholecystectomy does not work or if there are complications during surgery?
If the patient has certain complications associated with gallstones, the surgeon may need to remove the gallbladder with an open cholecystectomy. This surgery involves an incision in the abdomen and requires a longer hospital stay (three to five days). Medical issues that could lead to open cholecystectomy include:
- Having severe inflammation of the gallbladder.
- Experiencing difficulties during an attempted laparoscopic surgery.
- Having severe cardiac and respiratory issues.
- Having a late term pregnancy.
- Experiencing major scarring from a previous surgery.
- Having a bleeding disorder or liver disease.
- Having suspected gallbladder cancer, a very rare condition.
What is an endoscopic retrograde cholangiopancreatography (ERCP) procedure?
An endoscopic retrograde cholangiopancreatography (ERCP) procedure is another minimally invasive option for removing gallstones. The endoscope is a tube-like tool. Your doctor will need to move it throughout your digestive system during the treatment. The path the endoscope travels is:
- In the mouth.
- Down the throat.
- Through the stomach.
- Into the duodenum (beginning of the small intestine) where the common bile duct empties its bile.
Once there, the endoscope is used to remove any blockages in the bile duct.
Can I digest food without a gallbladder?
You don't need a gallbladder in order to digest food properly. If your gallbladder is removed, bile will flow directly from your liver through the hepatic duct and the common bile duct to the small intestine. After the surgery, you may experience some softer stools, which generally resolve over time.
Are there any non-surgical treatments for gallstones?
In most cases where gallstones need treatment, your healthcare provider will use a minimally invasive technique to remove the stone. There are medications that can be used to dissolve the stones. However, as minimally invasive methods have advanced, these drugs haven’t been used as often. Dissolving medications can take months—or possibly even years—to get rid of the gallstones. By contrast, a procedure resolves the issue quickly. Using these medications to treat gallstones could be an option if you are unable to have surgery because of another condition. Talk to your doctor about all treatment options and which one is the best fit for you.
What are the complications of gallstones?
There are several complications of a gallstone attack, including:
Gallstones can also cause the gallbladder or bile ducts to become infected. A blockage in the common bile duct can cause jaundice (yellowing of your skin or eyes) or can irritate the pancreas.
Can gallstones be prevented?
Gallstones cannot be prevented. However, you can decrease your risk factors by following healthy lifestyle tips. It is important to maintain a healthy weight through exercise and a balanced diet. Talking to your doctor about weight loss and cholesterol management is also a big part of preventing gallstones.
What foods should I avoid if I have had gallstones in the past?
Many gallstones are formed from cholesterol. Though you cannot prevent gallstones, you can try and limit the amount of fatty foods in your diet. Several tips for limiting cholesterol in your diet include:
- Eating less meat.
- Adding fish.
- Limiting the amount of fried foods.
- Adding more whole grains.
- Choosing low-fat dairy products (cheese, milk).
- Adding fresh vegetables and fruit.
Can I have gallstones more than once?
Yes. If you have experienced a gallstone attack once, it is more likely that you will have them again. The multiple attack nature of gallstones is why your doctor may suggest removing the gallbladder.
Outlook / Prognosis
Are gallstones fatal?
Gallstones themselves are not fatal. However, they can cause many complications that could be fatal. Fortunately, this is a rare event. If a large stone blocks your bile ducts after leaving the gallbladder, there could be a build-up of bile in the gallbladder and ducts, causing severe pain and an infection within the ducts. This is an urgent medical situation that needs prompt treatment, such as an emergency endoscopic retrograde cholangiopancreatography (ERCP). Of course, all medical procedures—such as ERCP and cholecystectomy—have risks.
How quickly will I recover from gallstones?
If gallstones cause symptoms, then you may need surgery. If you have a laparoscopic cholecystectomy (minimally invasive procedure to remove the gallbladder) without any complications, you may be home within 24 hours. If there are complicating factors—swelling of the gallbladder, infection, a blocked duct or other medical conditions may need to have an open surgery. If that happens, your hospital stay could be about three to five days.
When can I return to my normal activities after having gallstones?
If you have a gallstone that does not require treatment (silent stone) you can continue on with your normal activities right away. If you have a minimally-invasive procedure, you will need a short amount of time to recover before starting your activities again. Two major advantages of minimally-invasive procedures include a much faster recovery time and less pain. Larger, open surgeries traditionally mean more time in the hospital and a longer recovery at home. Speak with your doctor about a realistic plan for your recovery.
When should I call my doctor?
If you are experiencing pain in your abdomen, call your doctor, especially if the pain increases over time and is associated with fever, nausea or vomiting. Abdominal pain has many causes and your doctor will evaluate your symptoms carefully in order to make the correct diagnosis. If your symptoms are severe, then you may be directed to an emergency department for immediate evaluation.