Where are gallstones typically found. What causes gallstones to form. How are gallstones diagnosed and treated. What are the risk factors for developing gallstones. Can gallstones be prevented.

Understanding Gallstones: Formation and Location

Gallstones, medically known as cholelithiasis, are solid, pebble-like formations that develop in the gallbladder. The gallbladder is a small, pear-shaped organ located beneath the liver in the upper right quadrant of the abdomen. Its primary function is to store and concentrate bile, a digestive fluid produced by the liver.

Gallstones form when components of bile, such as cholesterol or bilirubin, precipitate and solidify. The process typically begins with the formation of biliary sludge, a thick, viscous mixture of bile salts, lecithin, and cholesterol. Over time, this sludge can crystallize and grow into gallstones of varying sizes.

Types of Gallstones

• Cholesterol stones: The most common type, comprising about 80% of gallstones
• Pigment stones: Made primarily of bilirubin, these are less common and often associated with certain medical conditions
• Mixed stones: A combination of cholesterol and pigment components
• Calcium stones: Rare stones formed from calcium salts

Do gallstones always cause symptoms? Interestingly, most gallstones are asymptomatic. In fact, many people have gallstones without ever realizing it. However, when gallstones do cause problems, they can lead to significant discomfort and potential complications.

The Epidemiology of Gallstones: Who Is at Risk?

Gallstones are a common condition, particularly in developed countries. In the United States alone, it’s estimated that over 20 million people between the ages of 20 and 74 have gallstones. The prevalence of gallstones increases with age, with a significant portion of the population over 60 affected.

Are gallstones more common in certain demographic groups? Indeed, several factors influence the likelihood of developing gallstones:

• Gender: Women are twice as likely as men to develop gallstones
• Age: The risk increases as you get older
• Ethnicity: Native Americans and Mexican Americans have higher rates of gallstones
• Obesity: Excess weight increases the risk of gallstone formation
• Rapid weight loss: Paradoxically, losing weight too quickly can also lead to gallstone formation
• Pregnancy: Hormonal changes during pregnancy increase the risk
• Family history: Genetics play a role in gallstone development

Understanding these risk factors can help individuals and healthcare providers assess the likelihood of gallstone formation and take appropriate preventive measures.

The Silent Stones: Recognizing Gallstone Symptoms

While many gallstones remain asymptomatic, when they do cause problems, the symptoms can be quite distinctive. The classic presentation of symptomatic gallstones is known as biliary colic, characterized by:

• Sudden, intense pain in the upper right abdomen or center of the abdomen
• Pain that may radiate to the right shoulder or between the shoulder blades
• Nausea and vomiting
• Pain that typically occurs after meals, especially fatty or greasy foods

How long do gallstone attacks typically last? Biliary colic episodes often last for several hours, usually subsiding as the gallstone moves and no longer blocks the bile duct. However, if the blockage persists, it can lead to more serious complications such as cholecystitis (inflammation of the gallbladder) or cholangitis (infection of the bile ducts).

It’s important to note that the severity and frequency of symptoms can vary greatly among individuals. Some may experience only mild discomfort, while others may have severe, debilitating pain that requires immediate medical attention.

Diagnosing Gallstones: From Suspicion to Confirmation

When gallstones are suspected, healthcare providers have several diagnostic tools at their disposal. The journey from suspicion to diagnosis typically involves a combination of clinical assessment and imaging studies.

Clinical Assessment

The diagnostic process usually begins with a thorough medical history and physical examination. The healthcare provider will inquire about the nature, duration, and triggers of the symptoms. They will also perform a physical exam, paying particular attention to the upper right quadrant of the abdomen.

Imaging Studies

What is the gold standard for diagnosing gallstones? Ultrasound is considered the most reliable and cost-effective method for detecting gallstones. It’s non-invasive, doesn’t involve radiation, and can detect stones as small as 2mm in diameter.

Other imaging techniques that may be used include:

• CT scan: Provides detailed images of the gallbladder and surrounding structures
• MRCP (Magnetic Resonance Cholangiopancreatography): Offers detailed images of the biliary system
• HIDA scan: Evaluates gallbladder function and can detect blockages in the bile ducts

In some cases, blood tests may be ordered to check for signs of infection or obstruction, such as elevated liver enzymes or bilirubin levels.

Treatment Options: From Conservative Management to Surgery

The treatment approach for gallstones depends largely on whether they are symptomatic and the severity of the symptoms. Let’s explore the various treatment options available:

Watchful Waiting

For asymptomatic gallstones, a “watch and wait” approach is often recommended. Many people with gallstones never develop symptoms and don’t require treatment. However, regular monitoring may be advised to ensure early detection of any complications.

Lifestyle Modifications

For those with mild or infrequent symptoms, lifestyle changes may be sufficient to manage the condition. These may include:

• Dietary changes: Reducing intake of fatty foods and maintaining a healthy weight
• Regular exercise: Can help with weight management and may reduce the risk of gallstone formation
• Staying hydrated: Adequate fluid intake may help prevent stone formation

Medications

In some cases, medications may be prescribed to dissolve gallstones. Ursodeoxycholic acid (Ursodiol) is the most commonly used medication for this purpose. However, it’s important to note that this treatment is typically only effective for small cholesterol stones and may take months or even years to work.

Surgical Intervention

What is the definitive treatment for symptomatic gallstones? Cholecystectomy, or surgical removal of the gallbladder, is considered the gold standard treatment for symptomatic gallstones. This procedure is typically performed laparoscopically, which involves making small incisions and using specialized instruments.

The benefits of laparoscopic cholecystectomy include:

• Shorter hospital stay
• Quicker recovery time
• Less postoperative pain
• Smaller scars

In some cases, open surgery may be necessary, particularly if there are complications or if the patient has had previous abdominal surgeries.

Living Without a Gallbladder: What to Expect After Cholecystectomy

Many people worry about the consequences of living without a gallbladder. However, the body can function quite well without this organ. The liver continues to produce bile, which flows directly into the small intestine instead of being stored in the gallbladder.

After gallbladder removal, most people can return to their normal diet. However, some individuals may experience changes in their digestive habits, such as:

• Increased frequency of bowel movements
• Looser stools
• Difficulty digesting fatty foods

These symptoms typically improve over time as the body adjusts to the absence of the gallbladder. In some cases, dietary modifications or medications may be recommended to manage persistent digestive issues.

Preventing Gallstones: Proactive Measures for Better Health

While not all risk factors for gallstones are modifiable, there are several steps individuals can take to reduce their risk of developing this condition:

Maintain a Healthy Weight

Obesity is a significant risk factor for gallstone formation. Maintaining a healthy weight through a balanced diet and regular exercise can help reduce this risk. However, it’s important to avoid rapid weight loss, as this can paradoxically increase the risk of gallstone formation.

Eat a Balanced Diet

A diet rich in fruits, vegetables, and whole grains, and low in saturated fats and refined carbohydrates may help prevent gallstones. Some studies suggest that moderate consumption of coffee and alcohol may also have a protective effect, although more research is needed in this area.

Stay Hydrated

Drinking plenty of water throughout the day can help prevent the concentration of bile in the gallbladder, potentially reducing the risk of stone formation.

Exercise Regularly

Regular physical activity not only helps maintain a healthy weight but may also improve gallbladder function and reduce the risk of gallstone formation.

Manage Underlying Health Conditions

Certain medical conditions, such as diabetes and metabolic syndrome, are associated with an increased risk of gallstones. Proper management of these conditions may help reduce this risk.

By implementing these preventive measures, individuals can take proactive steps towards maintaining gallbladder health and reducing their risk of developing gallstones.

The Role of Diet in Gallstone Management

Diet plays a crucial role in both the prevention and management of gallstones. While dietary changes alone may not be sufficient to treat existing gallstones, they can help prevent their formation and manage symptoms in those who already have them.

Foods to Include

A gallstone-friendly diet typically includes:

• High-fiber foods: Fruits, vegetables, whole grains, and legumes
• Lean proteins: Fish, poultry, and plant-based proteins
• Healthy fats: Olive oil, avocados, nuts, and seeds (in moderation)
• Calcium-rich foods: Low-fat dairy products, leafy greens, and fortified plant-based alternatives

Foods to Limit or Avoid

Certain foods may trigger gallbladder attacks or contribute to gallstone formation:

• Fatty, fried foods
• Highly processed foods
• Refined carbohydrates
• High-fat dairy products
• Red meat

How does diet influence gallstone formation? A diet high in cholesterol and low in fiber can increase the cholesterol content of bile, making it more likely to form stones. Conversely, a balanced diet rich in fiber can help promote regular bowel movements and reduce the concentration of cholesterol in bile.

It’s important to note that dietary needs can vary among individuals, and what triggers symptoms in one person may not affect another. Working with a healthcare provider or registered dietitian can help develop a personalized eating plan that supports gallbladder health while meeting individual nutritional needs.

Complications of Untreated Gallstones: When to Seek Help

While many gallstones remain asymptomatic, untreated symptomatic gallstones can lead to serious complications. Understanding these potential complications and recognizing when to seek medical attention is crucial for preventing more severe health issues.

Potential Complications

• Cholecystitis: Inflammation of the gallbladder
• Choledocholithiasis: Gallstones in the common bile duct
• Cholangitis: Infection of the bile ducts
• Pancreatitis: Inflammation of the pancreas
• Gallbladder cancer: A rare but serious complication of chronic gallstone disease

When should you seek immediate medical attention for gallstone symptoms? If you experience any of the following, it’s important to seek medical care promptly:

• Severe abdominal pain that doesn’t subside after several hours
• Fever and chills accompanying abdominal pain
• Jaundice (yellowing of the skin or eyes)
• Persistent nausea and vomiting
• Dark urine or clay-colored stools

These symptoms could indicate a more serious complication that requires immediate medical intervention. Prompt treatment can prevent the progression of these complications and reduce the risk of long-term health consequences.

In conclusion, while gallstones are a common condition, they can lead to significant health issues if left untreated. By understanding the risk factors, recognizing symptoms, and implementing preventive measures, individuals can take an active role in maintaining their gallbladder health. Regular check-ups and open communication with healthcare providers are key to early detection and effective management of gallstones.

Gallstones (Cholelithiasis) – StatPearls – NCBI Bookshelf

Mark W. Jones; Connor B. Weir; Sassan Ghassemzadeh.

Author Information and Affiliations

Last Update: April 24, 2023.

Continuing Education Activity

Gallstones or cholelithiasis are stones that form in the gallbladder composed of cholesterol, bilirubin, and bile. These stones are asymptomatic in most cases, with stones discovered incidentally. Symptomatic patients present with right upper abdominal pain after eating greasy or spicy food, nausea, vomiting, pain in epigastrium that radiates to the right scapula or mid-back. This activity illustrates the evaluation and management of gallstones and reviews the role of the interprofessional team in improving care for patients with this condition.

Objectives:

• Identify the risk factors associated with the development of gallstones.

• Describe the pathophysiology of gallstones.

• Outline the use of a right upper quadrant abdominal ultrasound in the evaluation of gallstones.

• Explain the importance of improving care coordination among the interprofessional team members to improve outcomes for patients affected by gallstones.

Access free multiple choice questions on this topic.

Introduction

Gallstones or cholelithiasis are responsible for one of the most prevalent digestive disorders in the United States. They are considered a disease of developed populations but are present around the world. It is both the result of a chronic disease process and the cause of subsequent acute disorders of the pancreatic, biliary, hepatic, and gastrointestinal tract. Over 6.3 million females and 14.2 million males in the United States between the ages of 20 and 74 have gallstones. Most patients with gallstones are asymptomatic, but 10% of patients will develop symptoms within five years, and 20% of patients will develop symptoms within 20 years of diagnosing gallstones. Gallstone prevalence also increases with age. Over one-quarter of females older than the age of 60 will have gallstones. Gallstones have various compositions and etiologies.[1]

The critical feature of gallstones is that they are not all symptomatic. Sometimes they may migrate near the opening of the cystic duct and block the flow of bile. This can lead to tension in the gallbladder, which results in the classic biliary colicky pain. If the cystic duct is obstructed for more than a few hours, it can lead to inflammation of the gallbladder wall (cholecystitis). Sometimes the gallstone may move into the bile duct and cause obstruction, leading to jaundice and abdominal pain. Patients who have chronic gallstones may develop progressive fibrosis and loss of motor function of the gallbladder. The best test to make a diagnosis of gallstones is ultrasound. The treatment of gallstones depends on symptoms. The standard of care for symptomatic patients is laparoscopic cholecystectomy.

Etiology

Gallstones usually form from sluggishly emptying of bile from the gallbladder. When bile is not fully drained from the gallbladder, it can precipitate as sludge, which in turn can develop into gallstones. Biliary obstruction from various causes such as strictures in the bile duct or neoplasms may also lead to gallstones. The most common cause of cholelithiasis is the precipitation of cholesterol from cholesterol-rich bile. The second most common form of gallstones is pigmented gallstones. These form from the breakdown of red blood cells and are black. The third type of gallstones is mixed pigmented stones, a combination of calcium substrates such as calcium carbonate or calcium phosphate, cholesterol, and bile. The fourth type of stone is calcium stones. These may be due to the precipitation of serum calcium in patients with hypercalcemia. Often these patients will have concurrent kidney stones.[2]

Risk factors for gallstones include:

• In pregnancy, progesterone decreases the contractility of the gallbladder leading to stasis.

• Obesity

• Genes

• Certain medications (estrogens, fibrates, somatostatin analogs)

• Stasis of the gallbladder

• Female gender

• Metabolic syndrome

• Rapid weight loss

• Prolonged fasting

• Bariatric surgery

• Crohn disease, ileal resection

Epidemiology

Most gallstones are asymptomatic. In the United States, approximately 14 million women and 6 million men with an age range of 20 to 74 have gallstones. The prevalence increases as a person ages. Obesity increases the likelihood of gallstones, especially in women, due to increases in the biliary secretion of cholesterol. On the other hand, patients with drastic weight loss or fasting have a higher chance of gallstones secondary to biliary stasis. Furthermore, there is also a hormonal association with gallstones. Estrogen has been shown to result in an increase in bile cholesterol as well as a decrease in gallbladder contractility. Women of reproductive age or on estrogen-containing birth control medication have a two-fold increase in gallstone formation compared to males. People with chronic illnesses such as diabetes also have an increase in gallstone formation and reduced gallbladder wall contractility due to neuropathy.[3]

Pathophysiology

Gallstones occur when substances in the bile reach their limits of solubility. As bile becomes concentrated in the gallbladder, it becomes supersaturated with these substances, which in time precipitate into small crystals. These crystals, in turn, become stuck in the gallbladder mucus, resulting in gallbladder sludge. Over time, these crystals grow and form large stones. Complications caused by gallstones are a direct consequence of occlusion of the hepatic and biliary tree by sludge and stones.[3]

There are two types of gallstones, cholesterol and calcium bilirubinate.

Cholesterol gallstones form the majority of gallstones. The major component of these stones is cholesterol. The bilirubinate stones contain bilirubin. In patients with a high turnover of heme, such as cirrhosis or chronic hemolysis, the unconjugated bilirubin will crystallize and eventually form stones. These stones are usually dark black or blue and account for about 15% of gallstones in the United States.

Sometimes, the cholesterol gallstones will become colonized with microorganisms, which leads to inflammation of the mucosa. The resulting leucocyte infiltration and presence of bilirubin leads to mixed stones.

Histopathology

Pathologists can analyze the composition of gallstones and bile, which may help to determine the cause of the stones, especially in cases of primary common bile duct stones, after gallbladder removal and the exact cause of the stones is unknown.[4][5]

History and Physical

Usually, patients with symptoms from gallstones present with right upper abdominal pain after eating greasy or spicy foods. There is often nausea and vomiting. Pain can also be present in the epigastric area that radiates to the right scapula or mid-back. The classic physical exam finding is a positive Murphy’s sign, where the pain is elicited on deep palpation to the right upper quadrant underneath the rib cage upon deep inspiration. Patients may be asymptomatic for months to years until the discovery of gallstones. Acute cholecystitis presents similarly. However, it is more severe. Jaundice can be a sign of a common bile duct obstruction from an entrapped gallstone.  In the presence of jaundice and abdominal pain, often, a procedure is an indication to go and retrieve the stone to prevent further sequelae. One such sequela is ascending cholangitis, with symptoms of right upper abdominal pain, fever, and jaundice (Charcot’s triad). Progression of this condition is indicated by neurologic changes and hypotension (Reynold’s pentad). Other sequelae are acute pancreatitis with symptoms of mid-epigastric pain and intractable vomiting.[6]

Evaluation

The best diagnostic test for diagnosing gallstones and subsequent acute cholecystitis is a right upper quadrant abdominal ultrasound. It is associated with a 90% specificity rate and, depending on the ultrasound operator, can detect stones as small as 2 mm as well as sludge and gallbladder polyps. Ultrasound findings that point towards acute cholecystitis versus cholelithiasis include gallbladder wall thickening greater than 3 mm, pericholecystic fluid, and a positive sonographic Murphy’s sign. Gallstones can also often be present on CT scans and MRIs. However, these tests are not as sensitive for diagnosing acute cholecystitis. Approximately 10% of gallstones may be found on routine plain films due to their high calcium content. If there is a suspected stone in the common bile duct based on ultrasound results, magnetic resonance cholangiopancreatography (MRCP) is the next step. If a common duct stone is identified on the MRCP, then the gold-standard test of an endoscopic retrograde cholangiopancreatogram (ERCP) should be performed by a gastroenterologist. A percutaneous transhepatic cholangiogram (PTHC) is also useful in diagnosing common bile duct stones if an ERCP is not possible.[7]

Treatment / Management

Cholecystectomy treats symptomatic gallstones. The laparoscopic approach is the standard of care. Open cholecystectomies are the option when it is not practical or advisable to do a laparoscopic procedure. It is not wise to only remove the gallstones as studies have shown that they recur after about one year. In cases of acute cholecystitis in critically ill patients or patients who are poor surgical candidates, a decompression cholecystostomy tube can be placed to temporize the patient until stable enough for definitive surgery. Common bile duct stones can be removed with a preoperative or postoperative ERCP, PTHC, or operatively with a common bile duct exploration. Ascending cholangitis needs to be addressed urgently by removing the blockage either with ERCP, PTHC, or surgery, as well as early antibiotic administration. In cases of nonacute cholecystitis and very poor surgical candidates, gallstones can be treated medically. Ursodiol is administered daily with the hope of dissolving the gallstones and has shown mixed success with some studies at best, showing less than a 50% response rate.[8]

Differential Diagnosis

Prognosis

Less than 50% of patients who have gallstones will develop symptoms. Today, the mortality rate following laparoscopic cholecystectomy is less than 1%; however, emergency cholecystectomy rates are 10% or greater. Other complications include retained stones in the bile duct, incisional hernia, and chronic right upper quadrant pain. Despite the fact that laparoscopic cholecystectomy is now the standard of care for symptomatic gallstones, the rates of injury to the bile duct during surgery continue to increase.

Complications

Complications from gallstones may include [9][10]:

• Gallbladder inflammation leading to cholecystitis

• Common bile duct blockage resulting in bile duct infection and jaundice

• Pancreatic duct blockage which can cause pancreatitis

• Cancer of the gallbladder

Deterrence and Patient Education

Patient education centers around maintaining a low-fat diet, medication adherence, explaining the pathophysiology of the condition, follow-up appointments to track progress, and explaining potential surgical interventions if they become necessary.

Enhancing Healthcare Team Outcomes

Gallbladder disease can be a difficult diagnosis. Early suspicion with proper testing will make the diagnosis. The condition is best managed by an interprofessional team. Having a skilled radiologist and emergency physician will often be the critical first step in properly diagnosing gallstones. Early intervention by an experienced surgeon is also vital. Practitioners should remember that not all gallstones will require surgery. The correct clinical decision must be made as a group recommendation between the primary care physician, nurse practitioner, radiologist, gastroenterologist, the patient, and the surgeon. The primary care clinicians should encourage patients to eat a healthy diet, maintain healthy body weight, eat a low-fat diet, and abstain from prolonged fasting. Nurses monitor patients perioperatively, educate patients and their families, and inform the team of changes in patient status. Close communication between the team members if vital to lower the morbidity of gallstones.[11][12][13]

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

Figure

Gallstone on point-of-care ultrasound. Contributed by Emory EM Ultrasound Section

Figure

CT Acute Cholecystitis Wall Thickening Pericholecystic Fluid Gallstone. Contributed by Scott Dulebohn, MD

Figure

Gallstones in a female. Image courtesy S Bhimji

Figure

Figure 1. 37-year old female diagnosed as gallstones with acute cholecystitis. The incidental findings ; a: US image show multiple hypoechoic lesions, some of them with comet-tail artifacts, raises the possibility of multiple biliary hamartoma; b: T2-weighted (more…)

Figure

Gallbladder Gallstones (Calculi), Common
bile duct, Pancreas, Intestine, Gallbladder, Gallstones, Liver. Illustration by Emma Gregory

References

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Tsai TJ, Chan HH, Lai KH, Shih CA, Kao SS, Sun WC, Wang EM, Tsai WL, Lin KH, Yu HC, Chen WC, Wang HM, Tsay FW, Lin HS, Cheng JS, Hsu PI. Gallbladder function predicts subsequent biliary complications in patients with common bile duct stones after endoscopic treatment? BMC Gastroenterol. 2018 Feb 27;18(1):32. [PMC free article: PMC6389262] [PubMed: 29486713]

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Rebholz C, Krawczyk M, Lammert F. Genetics of gallstone disease. Eur J Clin Invest. 2018 Jul;48(7):e12935. [PubMed: 29635711]

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Shabanzadeh DM. New determinants for gallstone disease?
. Dan Med J. 2018 Feb;65(2) [PubMed: 29393043]

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Del Pozo R, Mardones L, Villagrán M, Muñoz K, Roa S, Rozas F, Ormazábal V, Muñoz M. [Effect of a high-fat diet on cholesterol gallstone formation]. Rev Med Chil. 2017 Sep;145(9):1099-1105. [PubMed: 29424395]

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Charfi S, Gouiaa N, Mnif H, Chtourou L, Tahri N, Abid B, Mzali R, Boudawara TS. Histopathological findings in cholecystectomies specimens: A single institution study of 20 584 cases. Hepatobiliary Pancreat Dis Int. 2018 Aug;17(4):345-348. [PubMed: 30173787]

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Wilkins T, Agabin E, Varghese J, Talukder A. Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia. Prim Care. 2017 Dec;44(4):575-597. [PubMed: 29132521]

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Hiwatashi K, Okumura H, Setoyama T, Ando K, Ogura Y, Aridome K, Maenohara S, Natsugoe S. Evaluation of laparoscopic cholecystectomy using indocyanine green cholangiography including cholecystitis: A retrospective study. Medicine (Baltimore). 2018 Jul;97(30):e11654. [PMC free article: PMC6078678] [PubMed: 30045318]

8.

Hirajima S, Koh T, Sakai T, Imamura T, Kato S, Nishimura Y, Soga K, Nishio M, Oguro A, Nakagawa N. Utility of Laparoscopic Subtotal Cholecystectomy with or without Cystic Duct Ligation for Severe Cholecystitis. Am Surg. 2017 Nov 01;83(11):1209-1213. [PubMed: 29183521]

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Del Vecchio Blanco G, Gesuale C, Varanese M, Monteleone G, Paoluzi OA. Idiopathic acute pancreatitis: a review on etiology and diagnostic work-up. Clin J Gastroenterol. 2019 Dec;12(6):511-524. [PubMed: 31041651]

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Brägelmann J, Barahona Ponce C, Marcelain K, Roessler S, Goeppert B, Gallegos I, Colombo A, Sanhueza V, Morales E, Rivera MT, de Toro G, Ortega A, Müller B, Gabler F, Scherer D, Waldenberger M, Reischl E, Boekstegers F, Garate-Calderon V, Umu SU, Rounge TB, Popanda O, Lorenzo Bermejo J. Epigenome-Wide Analysis of Methylation Changes in the Sequence of Gallstone Disease, Dysplasia, and Gallbladder Cancer. Hepatology. 2021 Jun;73(6):2293-2310. [PubMed: 33020926]

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Patel SS, Kohli DR, Savas J, Mutha PR, Zfass A, Shah TU. Surgery Reduces Risk of Complications Even in High-Risk Veterans After Endoscopic Therapy for Biliary Stone Disease. Dig Dis Sci. 2018 Mar;63(3):781-786. [PubMed: 29380173]

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Genser L, Vons C. Can abdominal surgical emergencies be treated in an ambulatory setting? J Visc Surg. 2015 Dec;152(6 Suppl):S81-9. [PubMed: 26522504]

13.

Coleman J. Bile duct injuries in laparoscopic cholecystectomy: nursing perspective. AACN Clin Issues. 1999 Nov;10(4):442-54. [PubMed: 10865529]

Disclosure: Mark Jones declares no relevant financial relationships with ineligible companies.

Disclosure: Connor Weir declares no relevant financial relationships with ineligible companies.

Disclosure: Sassan Ghassemzadeh declares no relevant financial relationships with ineligible companies.

Symptoms, Causes, Treatment, and More

Gallstones are deposits of digestive fluid made of solidified substances found in bile, like cholesterol. They are common and may or may not produce symptoms. People with symptoms usually need to have their gallbladders taken out.

Read on to learn more about gallstones, the symptoms they can cause, and how to treat them.

Your gallbladder is a small organ in your upper right abdomen, right below your liver. It’s a pouch that stores bile, a green-yellow liquid that helps digestion. Issues with your gallbladder typically occur when something is blocking its bile duct—like a gallstone.

Most gallstones are created when substances found in bile, like cholesterol, harden. Gallstones are very common and routinely asymptomatic.

However, about 10 percent of people who are diagnosed with gallstones will develop noticeable symptoms within 5 years.

Photo: Bruce Blaus | Wikimedia Commons | https://commons.wikimedia.org/wiki/File:Gallstones.png

Gallstones can lead to pain in the upper right abdomen or the center of your stomach. You may experience gallbladder pain from time to time after you eat foods that are high in fat, such as fried foods, but the pain can occur at almost any time.

Pain caused by gallstone issues usually lasts for only a few hours, but it can feel severe.

If gallstones are left untreated or unidentified, the symptoms may increase to include:

• a high temperature
• rapid heartbeat
• yellowing of the skin and whites of the eyes (jaundice)
• itchy skin
• diarrhea
• chills
• confusion
• a loss of appetite

These symptoms can be signs of a gallbladder infection, or inflammation of the gallbladder, liver, or pancreas.

Because gallstone symptoms may mimic the symptoms of other serious issues like appendicitis and pancreatitis, no matter what, if you’re dealing with one or more of these issues — it’s time to see a doctor or get yourself to the ER.

If you need help finding a urologist, then check out our FindCare tool here.

Asymptomatic gallstones

Gallstones themselves don’t cause pain. Rather, pain occurs when gallstones block the movement of bile from the gallbladder.

According to the American College of Gastroenterology, about 80 percent of people who have gallstones have “silent gallstones.” This means they don’t experience pain or have symptoms. In these cases, your doctor may discover the gallstones from X-rays or during abdominal surgery.

The actual cause of gallstones is thought to be due to a chemical imbalance of bile inside of the gallbladder. While researchers still aren’t clear about what exactly causes that imbalance to happen, there are a few possible reasons:

Too much cholesterol in your bile

Having too much cholesterol in your bile can lead to yellow cholesterol stones. These hard stones may develop if your liver makes more cholesterol than your bile can dissolve.

Too much bilirubin in your bile

Bilirubin is a chemical produced during the normal breakdown of red blood cells. After it’s created, it passes through the liver and is eventually excreted out of the body.

Some conditions, such as liver damage and certain blood disorders, cause your liver to produce more bilirubin than it should. Pigment gallstones form when your gallbladder can’t break down the excess bilirubin. These hard stones are often dark brown or black.

Concentrated bile due to a full gallbladder

Your gallbladder needs to be able to empty its bile to function properly. If it fails to empty its bile content, the bile becomes overly concentrated, which can cause stones to form.

Most of the time, you won’t need treatment for gallstones unless they cause you pain. Sometimes you can pass gallstones without even noticing. If you’re in pain, your doctor will likely recommend surgery. In rare cases, medication may be used.

If you’re at high risk for surgery complications, there are a few nonsurgical ways to attempt to treat gallstones. However, if surgery isn’t performed, your gallstones may come back — even with additional treatment. This means you may need to keep an eye on your condition for the majority of your life.

Surgery

Cholecystectomy, which is surgery to remove the gallbladder, is one of the most common operations performed on adults in the United States. Because the gallbladder isn’t an essential organ, it’s possible to live a healthy life without it.

There are two types of cholecystectomy:

• Laparoscopic cholecystectomy. This is a common surgery that requires general anesthesia. The surgeon will usually make three or four incisions in your abdomen. They’ll then insert a small, lighted device into one of the incisions, check for stones, and carefully remove your gallbladder. You can usually go home on the day of the procedure or the day after if you have no complications.
• Open cholecystectomy.This surgery is typically performed when the gallbladder is inflamed, infected, or scarred. This surgery may also happen if problems occur during a laparoscopic cholecystectomy.

You may experience loose or watery stools after gallbladder removal. Removing a gallbladder involves rerouting the bile from the liver to the small intestine. Bile no longer goes through the gallbladder and it becomes less concentrated. The immediate result is a laxative effect that can cause diarrhea, but this issue should resolve on its own for most people.

Nonsurgical treatments

If surgery can’t be performed, such as if the patient is a much older individual, there are a few other ways doctors can try to get rid of your gallstones.

• Oral dissolution therapy typically includes using the medications ursodiol (Actigall) and chenodiol (Chenix) to break up gallstones. These medications contain bile acids, which work to break up the stones. This treatment is best suited for breaking up cholesterol stones and can take many months or years to work completely.
• Shock wave lithotripsy is another option. A lithotripter is a machine that generates shock waves that pass through a person. These shock waves can break gallstones into smaller pieces.
• Percutaneous drainage of the gallbladder involves placing a sterile needle into the gallbladder to aspirate (draw out) bile. A tube is then inserted to help with additional drainage. This procedure isn’t typically a first line of defense and tends to be an option for individuals who may not be suited for other procedures.

Some risk factors for gallstones are related to diet, while other factors are not as controllable. Uncontrollable risk factors are things like age, race, sex, and family history.

Lifestyle risk factors

• living with obesity
• a diet high in fat or cholesterol and low in fiber
• undergoing rapid weight loss
• living with type 2 diabetes

Genetic risk factors

• being born female
• being of Native American or Mexican descent
• having a family history of gallstones
• being 60 years or older

Medical risk factors

• living with cirrhosis
• being pregnant
• taking certain medications to lower cholesterol
• taking medications with a high estrogen content (like certain birth controls)

While some medications may increase your risk of gallstones, don’t stop taking them unless you have discussed it with your doctor and have their approval.

Your doctor will perform a physical examination that includes checking your eyes and skin for visible changes in color. A yellowish tint may be a sign of jaundice, the result of too much bilirubin in your body.

The exam may involve using diagnostic tests that help your doctor see inside your body. These tests include:

• Ultrasound. An ultrasound produces images of your abdomen. It’s the preferred imaging method to confirm that you have gallstone disease. It can also show abnormalities associated with acute cholecystitis.
• Abdominal CT scan. This imaging test takes pictures of your liver and abdominal region.
• Gallbladder radionuclide scan. This important scan takes about one hour to complete. A specialist injects a radioactive substance into your veins. The substance travels through your blood to the liver and gallbladder. On a scan, it can reveal evidence to suggest infection or blockage of the bile ducts from stones.
• Blood tests. Your doctor may order blood tests that measure the amount of bilirubin in your blood. The tests also help determine how well your liver is functioning.

To help improve your condition and reduce your risk of gallstones, try these tips:

• Eat fewer refined carbs (like cookies and white bread) and less sugar.
• Increase your intake of healthy fats, like fish oil and olive oil, which may help your gallbladder contract and empty on a regular basis.
• Eat the proper amount of fiber per day (women need about 25 grams a day, men need about 38 grams a day).
• Get some sort of physical activity every day.
• Keep yourself properly hydrated.

If you plan to lose weight, do it slowly. Rapid weight loss may increase your risk of gallstones and other health problems.

While there is no foolproof way to completely prevent gallstones, cholesterol seems to play a major role in their formation. If you have a family history of gallstones, your doctor may advise you to limit foods with a high saturated fat content. Some of these foods include:

• fatty meat, like sausage and bacon
• cakes and cookies
• lard and cream
• certain cheeses

Because people living with obesity are more predisposed to gallstones, keeping your weight within a moderate range is another way to limit the possibility of their formation.

If your doctor has diagnosed you with gallstones and decides you need surgery to remove them or your gallbladder, the outlook is often positive. In most cases of stone removal, stones don’t return.

If you aren’t able to have surgery and decide to take medication to dissolve the stones, the gallstones can return, so you and your doctor will need to monitor your progress.

If your gallstones aren’t causing symptoms, you will most likely not need to do anything. Still, you may want to make lifestyle changes to prevent them from getting bigger and causing problems.

Stones in the bile ducts – causes, symptoms, who treats

What should be done to diagnose and treat stones in the bile ducts ? To solve this problem, the first step for the patient is to make an appointment with a gastroenterologist. After the initial examination, the doctor may prescribe additional tests:

• Ultrasound of the abdominal cavity
• Abdominal MRI with MR cholangiography
• Abdominal CT with CT cholangiography
• endoscopic ultrasound
• endoscopic retrograde cholangiography.

Choledocholithiasis is the presence of gallstones in the common bile duct. Gallstones usually form in the gallbladder. The bile duct is a small tube that carries bile from the gallbladder to the intestines. The gallbladder is a pear-shaped organ below the liver in the upper right part of the abdomen. Stones usually remain in the gallbladder or pass unhindered through the common bile duct.

Bile duct symptoms

Gallstones in the bile duct may not cause symptoms for months or even years. But if the stone gets stuck in the duct and blocks it, you may feel the following symptoms:

• abdominal pain in the upper right or middle upper abdomen
• fever
• jaundice
• loss of appetite
• nausea and vomiting
• clay colored chair.

Pain caused by gallstones in the bile ducts may be sporadic or prolonged. Severe pain requires immediate medical attention. The most severe symptoms can be confused with a heart attack, such as a heart attack.

When a gallstone gets stuck in the bile duct, the bile can become infected. Infection bacteria spread rapidly and enter the liver. If this happens, the infection becomes life-threatening. Other possible complications include biliary cirrhosis and pancreatitis.

Causes of gallstones in the bile ducts

There are 2 types of gallstones: cholesterol gallstones and pigment gallstones.

Cholesterol gallstones often look yellow and are the most common type. Scientists believe that cholesterol gallstones are formed due to bile containing:

• too much cholesterol
• too much bilirubin
• insufficient amount of bile salts.

They also occur when the gallbladder is not emptied completely or often enough.

The cause of pigment stones is unknown. They appear in patients suffering from:

• cirrhosis of the liver
• biliary tract infection
• hereditary blood disorders in which the liver produces too much bilirubin.

Risk factors

Patients with gallstones or gallbladder disease are at risk for developing gallstones. Even patients who have had their gallbladder removed may experience this disease. The following factors increase the likelihood of developing gallstones:

• obese
• low-fiber, high-fat diet
• pregnancy
• long fasting
• rapid weight loss
• lack of exercise.

Some of these risk factors for gallstones can be reduced through lifestyle changes. Risk factors that cannot be changed include:

• age
• sex – women are more prone to gallstones
• family history – genetics play a role.

How a doctor diagnoses bile duct stones

If there are signs, a gastroenterologist will check for a gallstone in the common bile duct. He will use one of the following imaging modalities:

• transabdominal abdominal ultrasound, an imaging procedure that uses high-frequency sound waves to examine the liver, gallbladder, spleen, kidneys, and pancreas
• Abdominal CT – X-ray of the abdomen in cross section
• endoscopic ultrasound – an ultrasound transducer is inserted into a flexible endoscopic tube and inserted through the mouth to examine the digestive tract
• endoscopic retrograde cholangiography – a procedure used to detect stones, tumors and narrowings in the bile ducts
• magnetic resonance cholangiopancreatography – MRI of the gallbladder, bile ducts and pancreatic ducts
• percutaneous transhepatic cholangiogram – x-ray of the bile ducts.

Your doctor will also order one or more of the following blood tests to look for infection and check liver and pancreatic function:

• complete blood count
• bilirubin
• pancreatic enzymes
• liver function tests.

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Diagnosis and treatment of gallstones : Armedical

Treatment in Israel
State
hospital
Ichilov-Surasky. Official representative.

The gallbladder can form gallstones, which are pieces of hard material like crystals that form directly in the gallbladder. These pieces can be of different shapes, sizes, and presented in different quantities.

The gallbladder is a pear-shaped organ. It is located in the upper right side of the abdomen under the liver. Its main purpose is the accumulation of bile and its excretion at the right time through the bile ducts into the intestines. As you know, bile plays a supporting role in the process of digestion.

Bile is a liquid produced continuously by the liver and is brownish yellow in color. It contains water, bile salts, bilirubin, bile pigments, which gives bile its characteristic color. The amount of bile that the liver can produce per day is up to 3 cups. In turn, the gallbladder is able to store up to 1 cup of bile.

The presence of stones in the gallbladder usually does not cause serious discomfort or pain, but the danger is that they can travel through the bile ducts and block them. And this leads to violations of the outflow of bile and obstruction of the biliary tract.

In 80% of patients, gallstones are yellow, white or light in color due to their calcium and cholesterol content. The remaining 20% ​​are dark-colored stones, which contain bilirubin, which is insoluble in water. 85% of patients have cholesterol-type stones.

In terms of stone size, gallstones can be as small as a grain of sand. But they can also reach large sizes, comparable to the size of a ping-pong ball. There are times when one large stone can form in the gallbladder, and there are also an incredible number (up to a thousand) of small stones.

Stones in the gallbladder – the causes of the appearance

In the course of practice and study of the problem of gallstone disease, the specialists of the Ichilov Hospital made conclusions regarding the main causes of its occurrence:

• hereditary factors;
• overweight and sedentary;
• unhealthy diet and improper eating habits;
• chemical processes in the liver;
• dysmotility of the gallbladder, etc.

Cholesterol stones are formed if the bile contains an excess amount of cholesterol and there is a lack of bile salts, and also when there are proteins or bile in the liver. Also, another reason for the formation of stones is incomplete emptying of the gallbladder.

Symptoms of gallstone disease

Often, gallstone disease can be asymptomatic. But sometimes there may be pain in the upper abdomen on the right, in the right shoulder blade, chest or back. Nausea or vomiting may also be felt. There can be different intervals between such attacks – both a week and a year.
Even if there are no symptoms of the disease, it still needs to be treated, since blockage of the bile ducts can cause the development of jaundice or cholecystitis.

Methods for diagnosing gallstones in Ichilov Hospital

To diagnose gallstones, Ichilov Hospital (Tel Aviv Sourasky Medical Center) performs an ultrasound (an examination using ultrasound). When difficulties arise in identifying stones, other research methods may be required at the discretion of doctors: nuclear magnetic resonance, endoscopic ultrasound, magnetic resonance imaging, endoscopic retrograde cholangiopancreatography.

Methods of treatment of cholelithiasis

The main method of treatment of cholelithiasis is the removal of stones by laparoscopic surgery, during which visual control is carried out.