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Gallstones

 

Gallstones are small stones, usually made of cholesterol, that form in the gallbladder. In most cases, gallstones do not cause any symptoms.

However, in a small number of cases, gallstones can become trapped in a duct (an opening or channel), irritate and inflame the gallbladder, or move out of the gall bladder and into other parts of the body. This can lead to a range of symptoms, such as:

  • a sudden intense pain in your abdomen
  • nausea and vomiting
  • jaundice (yellowing of the skin and the whites of the eyes)

'Gallstone disease' is the general term that describes the symptoms and associated complications caused by gallstones.

The gallbladder

The gallbladder is a small, pear-shaped, pouch-like organ that is situated underneath the liver. The main purpose of the gall bladder is to store and concentrate bile.

Bile is a liquid that is produced by the liver, which is used to help with the digestion of 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 (stronger), increasing its effectiveness at digesting fats. The gallbladder is able to release bile into the digestive system when it is required.

While the gallbladder is a useful organ, it is not an essential one. You can safely have your gallbladder removed without it interfering with your ability to digest food.

Types of gallstone disease

There are three main types of gallstone disease:

  • Asymptomatic gallstones: gallstones are present in the gallbladder but do not cause any symptoms.
  • Uncomplicated gallstone disease: usually caused when gallstones block the opening to the bile duct. This usually leads to repeated episodes of abdominal pain that last for one to five hours. The episodes of pain usually occur infrequently. It may be several weeks or months before you experience a further episode.
  • Complicated gallstone disease: gallstones have triggered a range of more serious complications, such as inflammation of the gall bladder (cholecystitis). Symptoms of complicated gallstone disease are usually wide ranging and severe, and can include a high temperature (fever) of 38C (100.4F) or above, jaundice and constant abdominal pain.

How common are gallstones?

Gallstones are very common. It is estimated that 10-15% of the adult population have gallstones. In most cases, they are asymptomatic (do not cause symptoms).

Every year, it is estimated that 1-4% of people with asymptomatic gallstones develop uncomplicated or complicated gallstone disease. Most people usually experience the symptoms of uncomplicated gallstone disease before developing complications. However, not everyone with uncomplicated gallstone disease will also have complications.

Known risk factors for gallstones include:

  • Age: the older a person is, the more likely they are to develop gallstones.
  • Sex: women are two to three times more likely to develop gallstones than men.
  • Obesity.

Outlook

The outlook for gallstone disease is good. Both uncomplicated and complicated gallstone disease can be treated by surgically removing the gallbladder. This is a relatively straightforward procedure with a good success rate. However, not everyone with uncomplicated gallstone disease will require surgery if their symptoms are not particularly frequent or severe.

Even though gallstone disease can usually be easily and successfully treated, some of the complications of the condition can be life threatening. Most deaths occurred in people aged over 70.

Because of the risks associated with complicated gallstone disease, the condition may require immediate treatment. See Symptoms of gallstones for more information.

Glossary

Cholesterol

Cholesterol is a fatty substance made by the body that is found in blood and tissue. It is used to make bile acid, hormones and vitamin D.

Jaundice

Jaundice is a condition that causes yellowing of the skin and the whites of the eyes. It is brought on by liver problems.

Liver

The liver is the largest organ inside the body. Its main jobs are to secrete bile (to help digestion), detoxify the blood and change food into energy.

Gallbladder

The gallbladder is a small organ found just under the liver. It stores bile for digestion.

Inflammation

Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Uncomplicated gallstone disease

The most common symptom of uncomplicated gallstone disease is a type of abdominal pain known as biliary colic.

Biliary colic

Biliary colic is a sudden, intense pain that usually lasts between one and five hours (although sometimes it can last up to eight hours). The pain can be located in:

  • the centre of your abdomen, below your breastbone and above your umbilicus (bellybutton)
  • the upper right of your abdomen, with the pain radiating towards your shoulder blade

You will usually find that the pain of biliary colic is brought on by eating fatty foods. The pain may also wake you up during the night.

Biliary colic is usually an infrequent symptom of gallstone disease. 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:

  • nausea
  • vomiting
  • excessive sweating

Complicated gallstone disease

The three most common complications that can arise from complicated gallstone disease are:

  • inflammation of the gall bladder (acute cholecystitis)
  • inflammation of the bile ducts (acute cholangitis)
  • inflammation of the pancreas (acute pancreatitis)

Acute cholecystitis

Acute cholecystitis can develop when one of your bile ducts becomes blocked by gallstones. The blockage causes the gallbladder to become swollen, irritated and inflamed.

Symptoms of acute cholecystitis include:

  • pain in your upper abdomen that radiates 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 15% of people with acute cholecystitis will also have symptoms of jaundice.

Acute cholangitis

If the bile ducts become blocked, they are vulnerable to infection by bacteria. Infected bile ducts may become inflamed.

Symptoms of acute cholangitis include:

  • pain in your upper abdomen that radiates towards your shoulder blade
  • a high temperature
  • jaundice (yellowing of the skin and whites of the eyes)
  • chills
  • mental confusion
  • itchy skin
  • a general sense of feeling unwell

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 main symptom of acute pancreatitis is the sudden onset of pain in the centre of your upper abdomen.

The pain of acute pancreatitis often gets steadily worse until it reaches a constant ache. The ache can be severe and may travel from your abdomen and along your back. The pain may feel worse after you have eaten.

Leaning forward or curling up into a ball may help relieve the pain to some extent.

Other symptoms of acute pancreatitis can include:

  • nausea
  • vomiting
  • diarrhoea
  • loss of appetite
  • a high temperature (fever) of 38C (100.4F) or above
  • tenderness of the abdomen
  • less commonly, jaundice (yellowing of the skin and whites of the eyes)

When to seek medical advice

The best way to determine whether your symptoms are due to uncomplicated gallstone disease or complicated gallstone disease is to determine whether:

  • you have a high temperature
  • your symptoms of pain last longer than eight hours

If you do not have either of these two symptoms, it is likely that you have uncomplicated gallstone disease and you should make an appointment to visit your GP.

If you have either of the above two symptoms, contact your GP immediately for advice.

In some cases, complicated gallstone disease may be an emergency as it can lead to serious complications if it is left untreated. Therefore, it is advisable to get an expert opinion on your symptoms as soon as possible.


Glossary

Gallbladder
The gallbladder is a small organ found just under the liver. It stores bile for digestion.
Pain
Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.
Jaundice
Jaundice is a condition that causes yellowing of the skin and the whites of the eyes. It is brought on by liver problems.
Nausea
Nausea is when you feel like you are going to be sick.
Vomiting
Vomiting is when you bring up the contents of your stomach through your mouth.
Stools
Stool (also known as faeces) is the solid waste matter that is passed from the body as a bowel movement.
Fever
A high temperature, also known as a fever, is when someone's body temperature is 38C (100.4F) or above.

It is thought that gallstones develop because of an imbalance in the chemical composition of bile inside the gallbladder. Bile is a liquid that is produced by the liver to help digest fats.

As many gallstones are made up of cholesterol, it has been suggested that a high-cholesterol diet may contribute to this unknown.

However, many people who eat a high-cholesterol diet do not develop gallstones, so the precise role that is played by diet and cholesterol is still uncertain.

Known risk factors

Gallstones are more common in the following groups:

  • women, particularly those who have been pregnant
  • obese people
  • 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 (30% 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 (lung infection), meningitis (infection of the layers of the brain) and gonorrhoea (a sexually transmitted infection)

Women who are taking an oral contraceptive 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

A number of other possible risk factors have been suggested for gallstones. However, they have not yet been conclusively proven to increase your risk. They include:

  • having type 2 diabetes
  • lack of exercise
  • eating a high-calorie diet that includes lots of carbohydrates and fats

Asymptomatic gallstones

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

  • blood tests
  • cholesterol tests
  • ultrasound scans

Occasionally, gallstones are detected during X-rays.

Symptomatic gallstones

When you visit your GP with symptoms of gallstones, your GP will ask you about the pattern of your symptoms so that they can assess whether you may have complicated gallstone disease.

For example, they will want to know whether you have experienced a high temperature of 38C (100.4F) or above, a rapid heartbeat and jaundice.

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

A diagnosis of gallstones can be confirmed using an ultrasound scan. You may also be given a liver function test. This is a type of blood test that is used to assess the state of your liver. The test is used because, if gallstones have moved into your bile duct, the normal functioning of your liver will be disrupted.

If your symptoms suggest that you have uncomplicated gallstone disease, you will be given a referral for a routine ultrasound.

If your symptoms suggest that you have complicated gallstone disease, you may be admitted to hospital so that an ultrasound can be carried out as soon as possible.

Cholangiography

Once a diagnosis of gallstones has been confirmed, you may have a procedure called a cholangiography to obtain further information about the gallstones and the condition of your gallbladder.

A cholangiography uses a dye that shows up on X-rays. The dye will either be injected into your bloodstream so that it concentrates in your bile ducts and gallbladder, or inserted into your bile ducts 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. The X-rays will reveal any abnormality in your bile or pancreatic systems, such as an inflamed gallbladder or pancreas. If your gallbladder and bile systems are working normally, the dye will be absorbed through all the places that bile is meant to go (your liver, bile ducts, intestines and gallbladder).

If the dye does not appear in one or more of these places, it usually signifies that gallstones are causing an obstruction. By studying the X-ray images, the precise location of the gallstones can be identified.

Glossary

X-ray
An X-ray is a painless way of producing pictures of inside the body using radiation.
Ultrasound
Ultrasound scans are a way of producing pictures of inside the body using sound waves.
Gallbladder
The gallbladder is a small organ found just under the liver. It stores bile for digestion.
Blood
Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.
Catheter
A catheter is a thin, hollow tube, usually made of rubber, that is placed into the bladder to inject or remove fluid.
Cholesterol
Cholesterol is a fatty substance made by the body that is found in blood and tissue. It is used to make bile acid, hormones and vitamin D.

In cases of gallstones with no symptoms, a policy of 'watchful waiting' is recommended. This means you will receive no immediate treatment, but you should look out for any worsening of your condition and report any symptoms to your GP.

As a general rule, the longer you go without experiencing any symptoms, the less likely it is that your condition will worsen.

The treatment plan for uncomplicated gallstone disease will depend on the frequency and severity of your symptoms, and the effect they have on your quality of life.

If your symptoms are mild and infrequent, and your quality of life is largely unaffected, surgery is not usually recommended. You may be prescribed painkillers, which you can use to control the symptoms if you experience another episode of biliary colic.

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

Whenever possible, surgery is recommended for all cases of complicated gallstone disease.

Cholecystectomy

A cholecystectomy is the surgical removal of the gallbladder. There are two types of cholecystectomy:

  • laparoscopic cholecystectomy
  • open cholecystectomy

Laparoscopic cholecystectomy

The most widely used type of cholecystectomy is laparoscopic cholecystectomy, which is a type of 'keyhole' surgery.

During a laparoscopic cholecystectomy, the surgeon will make four small incisions (cuts), each about 1cm or less, in your abdomen wall. One incision will be made by your naval (bellybutton) and the other three will be made across your upper abdomen.

Your abdomen will be inflated with carbon dioxide gas that is passed through the incisions. Inflating your abdomen gives the surgeon a better view of your organs and more room in which to work.

The surgeon will pass an instrument called a laparoscope through one of the incisions. A laparoscope is a small, flexible tube that has a light source and a camera at one end. The camera transmits images of the inside of your abdomen or pelvis to a television monitor.

The surgeon will then pass small instruments down the laparoscope which can be used to remove your gallbladder and any gallstones. Once the procedure is complete, the incisions will be sealed.

The advantage of having a laparoscopic cholecystectomy is that, as only small incisions are made in your abdomen, you will not experience much post-operative pain. You should also recover quickly from the effects of the operation. Most people are able to return home either on the day of the surgery or the day after.

Open cholecystectomy

In some circumstances, a laparoscopic cholecystectomy may not be recommended. This may be due to technical reasons or safety concerns. A laparoscopic cholecystectomy may not be recommended if:

  • you are in the third trimester (the last three months) of your pregnancy
  • you are obese
  • you have cirrhosis (scarring of the liver)
  • you 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, the surgeon makes a large incision in your abdomen and removes your gallbladder.

An open cholecystectomy is an effective method of treating gallstone disease, but it has a longer recovery time compared with laparoscopic cholecystectomy. Most people take about six weeks to recover from the effects of an open cholecystectomy.

Alternative treatments

A number of alternative treatments are available for people who are unable or unwilling to have their gallbladder removed.

However, many of these methods are only effective in a minority of people with gallstones (estimated at around 1 in 10). Therefore, if alternative treatments fail, you may still require surgery.

The alternative treatment methods for gallstones are described below.

Ursodeoxycholic acid

Gallstones that are made of cholesterol can sometimes be treated using a medication called ursodeoxycholic acid, which slowly dissolves gallstones.

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

Ursodeoxycholic acid is taken orally (in tablet form), and a course of treatment can last up to two years.

To increase the effectiveness of the medication, eating a low-cholesterol diet may be recommended. Your GP can give you more information about your diet.

Side effects of ursodeoxycholic acid are uncommon and are usually mild. The most commonly reported side effects are:

  • nausea
  • vomiting
  • 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. Other types of oral contraceptive pills are not recommended because they can sometimes interact unpredictably with ursodeoxycholic acid.

Endoscopic retrograde cholangiopancreatolography (ERCP)

Endoscopic retrograde cholangiopancreatolography (ERCP) is a procedure that aims to remove your gallstones without removing your gallbladder. It is usually carried out under a local anaesthetic, 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 gallstones are then removed or left to pass into your intestine.

 

Glossary

Cholesterol
Cholesterol is a fatty substance made by the body that is found in blood and tissue. It is used to make bile acid, hormones and vitamin D.
Gallbladder
The gallbladder is a small organ found just under the liver, which stores bile for digestion.
Incision
An incision is a cut made in the body with a surgical instrument during an operation.
Stools 
Stool (also known as faeces) is the solid waste matter that is passed from the body as a bowel movement.

Is it true that drinking a pint of lemon juice and olive oil gets rid of gallstones?

No. It’s either an old wives’ tale or a charlatan’s trick, depending on your point of view. You'll only end up passing solidified olive oil and the ‘treatment’ is often very painful.

Surgery Q&A

 

How long will I be in hospital after gallbladder removal?

Most people remain in hospital for one night, although you may be able to go home on the same day.

How long is recovery?

You should take it slowly for the first few days and avoid strenuous activity. Most people can return to work after about one to two weeks.

Can my body cope without a gallbladder?

The body does not need a gallbladder to function properly. After the gallbladder has been removed, bile dribbles continuously into the intestine and digestion is usually unaffected.

What will happen if I don't have surgery?

It's usually safe to live with gallstones, but they can lead to painful and serious health complications. Be aware of the risks involved when deciding not to have an operation.

Cancer of the gallbladder

Cancer of the gallbladder is a rare but serious complication of gallstones.

Having a history of gallstones is a major risk factor for developing gallbladder cancer. Approximately 80% of people who have cancer of the gallbladder also have a history of gallstones.

However, people with a history of gallstones have a less than 1 in 10,000 chance of developing gallbladder cancer.

If you have additional risk factors, such as a family history of gallbladder cancer, it may be recommended that your gallbladder be removed as a precaution, even if you only have asymptomatic gallstones (no 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 (yellowing of the skin and eyes)

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.

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
  • vomiting
  • 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 rupture (split). This could cause internal bleeding and widespread infection.

If you suspect that you have an obstructed bowel, contact your GP 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.

Many of the risk factors for gallstones, such as age and gender, are fixed and cannot be prevented.

However, from the limited evidence available, the most effective way of preventing gallstones is to make lifestyle changes, such as:

  • changes to your diet
  • losing weight (if you are obese)

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 whole grains.

There is also evidence that regularly eating nuts, such as peanuts or cashew nuts, can help reduce the risk of developing gallstones, as can drinking alcohol in moderation (no more than 21 standard drinks a week for men and 14 for women.

Losing weight

Being overweight, and particularly being obese, increases the amount of cholesterol that is 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.


Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.