Gallstones: Who Needs Surgery and Who Can Leave Them Alone
Gallstones turn up on abdominal ultrasounds all the time, often ordered for something else entirely. The useful question is not whether you have them, but whether they have ever caused a problem.
What the gallbladder does
The liver produces bile continuously. The gallbladder stores and concentrates it, then contracts after a fatty meal, squirting bile into the small intestine to help digest fat.
Gallstones form when the components of bile fall out of solution. Most are cholesterol stones; a minority are pigment stones, associated with conditions that break down red blood cells rapidly, and with chronic biliary infection.
Risk factors
- Female sex, with oestrogen raising cholesterol saturation in bile
- Increasing age
- Pregnancy and multiple pregnancies
- Obesity
- Rapid weight loss, including after bariatric surgery or very low calorie diets, which is a strong and often forgotten risk
- Diabetes
- Family history
- Certain medicines, including oestrogen therapy
- Prolonged fasting or intravenous nutrition, which leaves the gallbladder stagnant
Silent stones
The majority of people with gallstones never develop symptoms. Studies following people with incidentally found stones show that only a modest proportion go on to have problems, and most who do get a warning episode first rather than a catastrophe.
Standard practice is therefore no surgery for truly asymptomatic stones in most people. Exceptions where removal may be advised include a calcified “porcelain” gallbladder, very large stones, gallbladder polyps above a certain size, and certain haemolytic conditions.
Biliary colic: the warning episode
The classic symptomatic event is not really a colic at all, despite the name.
- Steady, severe pain in the right upper abdomen or just below the breastbone
- Builds over minutes, plateaus, then subsides over 30 minutes to a few hours
- Often after a fatty meal, frequently at night
- May radiate to the right shoulder blade or between the shoulders
- Nausea and vomiting
- Between episodes you feel entirely normal
Once biliary colic has happened, it tends to recur, and the risk of a more serious complication rises. This is usually the point at which surgery is recommended.
When it becomes an emergency
Acute cholecystitis. A stone blocks the gallbladder outlet and the gallbladder becomes inflamed and infected. Pain lasts more than several hours, there is fever, tenderness is marked, and the person feels genuinely unwell.
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Choledocholithiasis. A stone passes into the common bile duct and obstructs it. Jaundice, dark urine, pale stools, itching.
Ascending cholangitis. Infection of an obstructed bile duct. The classic triad is fever with rigors, jaundice and right upper abdominal pain. This can progress to sepsis quickly and is a medical emergency requiring urgent drainage.
Gallstone pancreatitis. A stone obstructs the pancreatic duct outlet. Severe pain boring through to the back, vomiting, and a markedly raised amylase or lipase.
Seek emergency care for: pain lasting more than a few hours, fever with abdominal pain, yellowing of the eyes or skin, pain radiating to the back with persistent vomiting, or confusion with any of these.
Investigation
Ultrasound is the first and usually sufficient test for gallbladder stones.
Liver function tests suggest duct involvement when bilirubin and alkaline phosphatase rise.
MRCP, a magnetic resonance scan of the biliary tree, is used when a duct stone is suspected.
ERCP is both diagnostic and therapeutic, allowing duct stones to be removed endoscopically.
Note that ultrasound is much less reliable at seeing stones inside the bile duct than inside the gallbladder, which is why a normal ultrasound does not exclude a duct stone when the blood tests suggest one.
Surgery
Laparoscopic cholecystectomy is the standard: removal of the whole gallbladder through several small incisions, usually as a day case or one overnight stay, with return to normal activity in one to two weeks.
The gallbladder is removed rather than just the stones, because a gallbladder that formed stones will form more. Procedures that only remove or dissolve stones have high recurrence and are reserved for people who cannot have surgery.
A proportion of operations are converted to open surgery because of inflammation or unclear anatomy, which is a safety decision rather than a complication.
Living without a gallbladder
Bile still flows from the liver into the intestine, just continuously rather than in a bolus. Most people notice no difference at all.
A minority experience looser stools or urgency after fatty meals in the first weeks to months, which usually settles as the bile ducts adapt. A small number have persistent bile acid diarrhoea, which is treatable with bile acid sequestrants and is worth raising rather than enduring.
There is no required long-term diet after gallbladder removal. Reintroduce fat gradually over the first few weeks.
Prevention
Maintain a healthy weight but lose it gradually rather than crash dieting, avoid prolonged fasting, eat regular meals including some fat so the gallbladder empties, and keep fibre intake reasonable.
Ursodeoxycholic acid can dissolve small cholesterol stones over many months, but works in a minority, requires ongoing treatment, and stones usually return when it stops.
The short version
Stones found by accident with no symptoms are usually left alone. One episode of biliary colic changes that, because episodes recur and complications follow. Pain lasting more than a few hours, fever, or yellowing of the eyes means hospital the same day, and removal of the gallbladder rather than the stones is what prevents it happening again.