Gallstones: What Do They Mean?

Gallstones (cholelithiasis) form when substances in the bile inside the gallbladder precipitate out and harden. They are common, and in many people they cause no symptoms at all and are found incidentally on an ultrasound done for another reason.

Having stones in the gallbladder does not by itself mean an operation is needed. What matters is whether the stones are causing symptoms or complications.

Why do gallstones form?

Most gallstones are cholesterol stones. An imbalance in the make-up of the bile, a gallbladder that does not empty well, and certain personal risk factors can all make stones more likely.

The risk can rise with;

• Increasing age
• Female sex
• Excess weight and obesity
• Rapid weight loss
• Pregnancy
• A family history of gallstones
• Diabetes and some metabolic conditions
• Some bowel diseases
• Some blood disorders

But in a good many people with gallstones no clear cause can be shown.

What symptoms do gallstones cause?

Most stones are silent.

When they do cause symptoms, the typical picture is the pain known as biliary colic. It usually begins in the right upper abdomen or the upper stomach, builds up, and can last from thirty minutes to several hours. The pain may spread to the right shoulder or the back, and nausea and vomiting may come with it.

It can come on after a heavy or fatty meal, but it does not have to be related to food.

What problems can gallstones lead to?

A stone may sit quietly in the gallbladder, or it may move and cause various complications.

• Blocking the gallbladder duct → acute cholecystitis Inflammation can develop in the gallbladder. The right upper abdominal pain lasts longer, and fever and tenderness may accompany it.
• Falling into the main bile duct → bile duct stone Jaundice, disturbance of the liver tests and infection of the bile ducts can develop.
• Blocking the duct and affecting the pancreas → acute pancreatitis Can run with severe upper abdominal pain and vomiting.
• Infection in the bile ducts → acute cholangitis Fever, jaundice and abdominal pain together are an important warning and need urgent assessment.

Do gallstones turn into cancer?

Gallstones are not cancer, and a stone itself does not turn into cancer.

Gallbladder cancer is rare. Although risk associations can be found with long-standing and particular gallbladder diseases, the great majority of people with gallstones never develop gallbladder cancer.

Does the size of the stone matter?

The size and number of stones are given in the ultrasound report, but the decision to treat is not made on the diameter of the stone alone.

Very small stones, or microlithiasis, can pass into the bile duct and cause pancreatitis, while large stones may stay in the gallbladder.

So there is no simple rule that “small stones are harmless and large stones are dangerous”.

What is biliary sludge?

Biliary sludge is a build-up of microscopic crystals and thickened material within the bile.

It can sometimes disappear on its own. But in some people it can be a forerunner of stone formation, or it can be associated — as stones are — with biliary colic, cholecystitis and pancreatitis.

How is the diagnosis made?

The first choice for assessing gallstones is usually ultrasound.

Ultrasound can show;

• Whether stones are present
• Their number and size
• The gallbladder wall
• Changes around the gallbladder
• Any widening of the bile ducts

If a stone in the main bile duct is suspected, blood tests together with further investigation such as MRCP or EUS may be needed.

If there are gallstones, is surgery needed?

Not every gallstone is operated on.

Where stones cause no symptoms at all and are found incidentally, routine surgery is mostly not needed, apart from particular risk situations.

Where the stones cause typical biliary pain or lead to complications, laparoscopic cholecystectomy — removing the gallbladder — is the mainstay of treatment.

At operation it is not only the stones that are taken out but the gallbladder itself. If only the stones were removed, new ones could form in the gallbladder.

Can gallstones be dissolved with medicine?

In certain selected cholesterol stones, dissolution treatment with ursodeoxycholic acid may be considered; but it is not suitable for every patient, treatment can take a long time, and the stones can come back.

For that reason the standard treatment of symptomatic gallstones is, in most situations, surgical.

What happens if the gallbladder is removed?

The gallbladder does not make bile; it stores the bile the liver makes.

When the gallbladder is removed, the liver goes on making bile and the bile flows straight into the bowel. Most people carry on with a normal life without a gallbladder.

When should a doctor be seen urgently?

In someone with gallstones, do not wait if there is;

• Severe right upper abdominal pain lasting hours
• Fever or shivering
• Jaundice
• Persistent vomiting
• Severe upper abdominal pain spreading to the back
• Dark urine and pale stools
• A marked deterioration in general condition

In short

• Gallstones Are very common, and most are silent.
• A gallstone Is not cancer.
• The typical finding Is biliary pain in the right upper abdomen or upper stomach.
• Not every wind and bloating Comes from gallstones.
• The first investigation Is usually ultrasound.
• A stone that falls into the bile duct Can cause jaundice, cholangitis or pancreatitis.
• A stone causing symptoms or complications May need surgical treatment.
• An incidental stone causing no symptoms Does not always need an operation.