Gallstones

Gallstones are small stones that form in the gallbladder, and they're usually made of cholesterol. Most of the time they cause no symptoms and don't need treatment.

But if a gallstone gets trapped in a duct (opening) inside the gallbladder, it can bring on a sudden, intense pain in the abdomen that usually lasts between 1 and 5 hours. This kind of abdominal pain is called biliary colic.

Some people with gallstones also develop complications, such as inflammation of the gallbladder (cholecystitis). This can cause:

• persistent pain
• jaundice
• a fever

When gallstones cause symptoms or complications, the condition is known as gallstone disease or cholelithiasis. Read more about:

• symptoms of gallstones
• complications of gallstones

The gallbladder is a small, pouch-like organ that sits underneath the liver. Its main job is to store bile and make it more concentrated.

Bile is a liquid the liver makes to help digest fats. It travels from the liver through a set of channels called bile ducts and ends up in the gallbladder.

The bile stays there, and as time passes it becomes more concentrated, which makes it better at digesting fats. When the body needs it, the gallbladder releases the bile into the digestive system.

Gallstones are thought to form when the chemical make-up of bile inside the gallbladder goes out of balance. In most cases the cholesterol in the bile becomes too high, and the extra cholesterol hardens into stones.

Gallstones are very common. It's estimated that more than 1 in every 10 adults in the UK has them, although only a minority of people ever develop symptoms.

You're more at risk of developing gallstones if you're:

• overweight or obese
• female, particularly if you've had children
• 40 or over (the risk increases as you get older)

Read more about:

• causes of gallstones
• preventing gallstones

You usually only need treatment for gallstones if they are causing:

• symptoms, such as abdominal pain
• complications, such as jaundice or acute pancreatitis

In these cases, keyhole surgery to remove the gallbladder may be recommended. The procedure is called a laparoscopic cholecystectomy. It is relatively simple to perform and has a low risk of complications.

You can lead a perfectly normal life without a gallbladder. Your liver will still produce bile to digest food, but the bile just drips continuously into the small intestine instead of building up in the gallbladder.

Read more about:

• treating gallstones
• diagnosing gallstones

Most cases of gallstone disease are easily treated with surgery. Very severe cases can be life-threatening, especially in people who are already in poor health. But deaths from gallstone disease are rare in the UK.

Most people with gallstones never notice any symptoms. But if a gallstone blocks one of the bile ducts, it can cause sudden, severe pain in the abdomen. This pain is known as biliary colic.

If the blockage is more severe, or it happens in another part of the digestive system, other symptoms may develop.

Gallstones can cause sudden, severe pain in the abdomen, and this is called biliary colic. The pain usually lasts 1 to 5 hours, though sometimes it passes in just a few minutes.

You can feel the pain:

• in the centre of your abdomen (tummy)
• just under the ribs on your right-hand side, and from there it may spread to your side or shoulder blade

The pain is constant. It doesn't ease when you go to the toilet, pass wind or are sick. Eating fatty foods can sometimes trigger it, but it can come at any time of day and may wake you up at night.

Biliary colic doesn't happen often. After one episode of pain, it may be several weeks or months before you have another.

Some people also sweat excessively and feel sick or vomit during these periods.

When gallstones cause episodes of biliary colic, doctors call it "uncomplicated gallstone disease".

In a small number of people, gallstones cause more serious problems. This happens when a stone blocks the flow of bile for longer, or moves into other organs (such as the pancreas or small bowel).

If this happens, you may develop:

• a high temperature of 38C (100.4F) or above
• more persistent pain
• a rapid heartbeat
• yellowing of the skin and whites of the eyes (jaundice)
• itchy skin
• diarrhoea
• chills or shivering attacks
• confusion
• a loss of appetite

Doctors call this more severe condition 'complicated gallstone disease'.

If you think you may be having biliary colic, make an appointment to see a doctor.

Contact a doctor straight away if you develop:

• jaundice
• abdominal pain lasting longer than eight hours
• a high temperature and chills
• abdominal pain so intense that you can't find a position to relieve it

Doctors think gallstones form when the chemical balance of bile inside the gallbladder goes wrong. Bile is a liquid the liver makes to help with digestion.

Nobody knows exactly what causes this imbalance, but gallstones can form if:

• there is an unusually high level of cholesterol inside the gallbladder (about 4 in every 5 gallstones are made up of cholesterol)
• there is an unusually high level of a waste product called bilirubin inside the gallbladder (about 1 in every 5 gallstones is made up of bilirubin)

These imbalances cause tiny crystals to develop in the bile. Over time, often many years, the crystals can grow into solid stones. A stone may be as small as a grain of sand or as large as a pebble.

Sometimes only 1 stone forms, but often there are several at the same time.

Gallstones are more common if you:

• are female, particularly if you've had children, are taking the combined Pill, or are having high-dose oestrogen therapy
• are overweight or obese
• are aged 40 years or older (the older you are, the more likely you are to develop gallstones)
• have a condition that affects the flow of bile, such as cirrhosis (scarring of the liver), primary sclerosing cholangitis, or obstetric cholestasis
• have Crohn's disease or irritable bowel syndrome (IBS)
• have a close family member who has also had gallstones
• have recently lost weight (from either dieting or weight-loss surgery)
• are taking an antibiotic called ceftriaxone

Gallstones often cause no symptoms at all, so they're sometimes found by chance when you have tests for a different condition.

If you do have symptoms of gallstones, make an appointment with your doctor so they can try to find out what the problem is.

Your doctor will ask you about your symptoms in detail. They may also do a test called Murphy's sign to help find out if your gallbladder is inflamed.

For this test, the doctor puts a hand or fingers on the upper-right area of your tummy and asks you to breathe in. If that hurts, it usually means your gallbladder is inflamed, and you may need urgent treatment.

The doctor may also suggest blood tests. These can look for signs of infection, or check whether your liver is working normally. If gallstones have moved into your bile duct, the liver may not be able to work properly.

If your symptoms and test results point to gallstones, your doctor will usually send you for further tests. And if your symptoms suggest a more severe form of gallbladder disease, you may be admitted to hospital for tests on the same day.

Doctors can usually confirm gallstones with an ultrasound scan. It uses high frequency sound waves to make a picture of the inside of your body.

The scan is much like the one done during pregnancy. A small handheld device called a transducer is placed on your skin and moved over your upper abdomen. It sends sound waves through your skin and into your body, and they bounce back off the body tissues. This forms an image on a monitor. The scan doesn't hurt, and it usually takes about 10 to 15 minutes.

Even when gallstones are found, there may be some doubt about whether any stones have passed into the bile duct. Stones in the bile duct are sometimes seen on the ultrasound. If they're not visible but your tests suggest the bile duct may be affected, you may need an MRI scan or a cholangiography.

Doctors may ask for a magnetic resonance imaging (MRI) scan when they want to look for gallstones in the bile ducts. The scan uses strong magnetic fields and radio waves to build up detailed pictures of the inside of your body.

A test called cholangiography can tell your doctor more about the condition of your gallbladder, including whether you have gallstones.

It uses a dye that shows up on X-rays. The dye may be injected into your bloodstream, or straight into your bile ducts. That can be done during surgery, or with an endoscope passed through your mouth.

Once the dye is in, X-ray images are taken. They'll reveal any abnormality in your bile or pancreatic systems. If your gallbladder and bile systems are working normally, the dye is absorbed in the places it's meant to go (your liver, bile ducts, intestines and gallbladder).

If the test finds a blockage, your doctor may try to remove it then and there using an endoscope. This is known as an endoscopic retrograde cholangio-pancreatography (ERCP). See the section on treating gallstones for more about ERCP.

A computerised tomography (CT) scan may be done to check for complications of gallstones, such as acute pancreatitis. The scan takes a series of X-rays from many different angles.

Doctors often use CT scans in an emergency to find the cause of severe abdominal pain.

How you treat gallstones depends on how much the symptoms get in the way of your daily life.

If you don't have any symptoms, doctors often recommend "active monitoring". This means you won't get treatment straight away, but you should tell your doctor if you notice any symptoms. As a general rule, the longer you go without symptoms, the less likely it is that your condition will get worse.

You may need treatment if you have another condition that raises your risk of complications, such as:

• scarring of the liver (cirrhosis)
• high blood pressure inside the liver, which is known as portal hypertension and is often a complication of alcohol-related liver disease
• diabetes

Treatment may also be recommended if a scan shows high levels of calcium inside your gallbladder, because this can lead to gallbladder cancer in later life.

If you have episodes of abdominal pain (biliary colic), the treatment depends on how the pain affects your daily activities. When the episodes are mild and don't come often, you may be given painkillers to control further episodes, along with advice about eating a healthy diet to help control the pain.

If your symptoms are more severe and happen frequently, surgery to remove the gallbladder is usually recommended.

The gallbladder isn't an essential organ, and you can lead a perfectly normal life without one. Some people do get bloating and diarrhoea after eating fatty or spicy food. If certain foods trigger your symptoms, you may wish to avoid them in future.

If your doctor recommends surgery for gallstones, you'll usually have keyhole surgery to remove your gallbladder. The medical name for this is a laparoscopic cholecystectomy.

During the operation, 3 or 4 small cuts are made in your abdomen. One larger cut (about 2cm to 3cm) goes by the belly button, and the others (each 1cm or less) are on the right side of your abdomen.

Your abdomen is temporarily inflated with carbon dioxide gas. This is harmless, and it makes it easier for the surgeon to see your organs.

A laparoscope is then put in through one of the cuts. It's a long thin telescope with a tiny light and video camera at the end, so your surgeon can watch the operation on a video monitor. The surgeon removes your gallbladder using special surgical instruments.

If the surgeon thinks there may be gallstones in the bile duct, an X-ray or ultrasound scan of the bile duct is also taken during the operation. If stones are found, they may be removed during the keyhole surgery. If the operation can't be done this way, or an unexpected complication occurs, it may have to be converted to open surgery.

Once the gallbladder is out, the gas in your abdomen escapes through the laparoscope. The cuts are closed with dissolvable stitches and covered with dressings.

A laparoscopic cholecystectomy is usually done under a general anaesthetic. This means you'll be asleep during the procedure and won't feel any pain while it's carried out. The operation takes 60 to 90 minutes and you can usually go home the same day. Full recovery typically takes around 10 days.

Single-incision laparoscopic cholecystectomy is a newer type of keyhole surgery used to remove the gallbladder. Only one small cut is made, so you'll have just one barely visible scar.

But this operation hasn't been carried out as often as the conventional laparoscopic cholecystectomy, so there are still some uncertainties about it. Access is also limited, because it needs an experienced surgeon with specialist training.

The National Institute for Health and Care Excellence (NICE) has more information on single-incision laparoscopic cholecystectomy.

A laparoscopic cholecystectomy (keyhole surgery to remove the gallbladder) may not always be recommended. For example, it may not suit you if you:

• are in the third trimester (the last three months) of pregnancy
• are extremely overweight
• have an unusual gallbladder or bile duct structure that makes a keyhole procedure difficult and potentially dangerous

In these cases, your doctor may recommend an open cholecystectomy instead. The surgeon makes a cut of 10cm to 15cm (4in to 6in) in your abdomen, underneath the ribs, so the gallbladder can be taken out. You'll be under general anaesthetic, so you'll be asleep and won't feel any pain.

Open surgery is just as effective as laparoscopic surgery. But recovery takes longer and the scar is more visible. Most people stay in hospital for up to 5 days, and it typically takes 6 weeks to recover fully.

An endoscopic retrograde cholangio-pancreatography (ERCP) is a procedure that can remove gallstones from the bile duct. Your gallbladder stays in place during it, so any stones inside the gallbladder will remain unless they're taken out with the surgical techniques mentioned above.

ERCP is similar to a diagnostic cholangiography (see diagnosing gallstones for more information). An endoscope, which is a long, thin, flexible tube with a camera at the end, is passed through your mouth down to the point where the bile duct opens into the small intestine.

During ERCP, though, the opening of the bile duct is widened with a small incision or an electrically heated wire. The bile duct stones are then either removed or left to pass into your intestine and out of your body.

Sometimes a small tube called a stent is placed in the bile duct permanently, to help the bile and stones pass.

An ERCP is usually done under sedation. This means you'll be awake throughout the procedure but won't feel any pain.

The procedure lasts about 30 minutes on average, but it can take anywhere from 15 minutes to over an hour. You may need to stay overnight in hospital afterwards so you can be monitored.

If your gallstones are small and don't contain calcium, you may be able to take ursodeoxycholic acid tablets to dissolve them.

Doctors don't prescribe these very often, though, because:

• they're rarely very effective
• they need to be taken for a long time (up to 2 years)
• gallstones can recur once treatment is stopped

Side effects of ursodeoxycholic acid are uncommon and are usually mild. The ones people report most often are feeling sick, being sick and itchy skin.

Ursodeoxycholic acid isn't usually recommended for pregnant or breastfeeding women. If you are a sexually active woman, use either a barrier method of contraception, such as a condom, or a low-dose oestrogen contraceptive pill while taking the tablets, because they may affect other types of oral contraceptive pills.

Sometimes ursodeoxycholic acid tablets are also prescribed as a precaution, if you're thought to be at risk of developing gallstones. For example, you may be given them if you've recently had weight loss surgery, as rapid weight loss can cause gallstones to grow.

Most people with gallstones never run into serious trouble, but a small number do. It can happen if a gallstone causes a severe blockage, or if it moves into another part of the digestive system.

Sometimes, in gallstone disease, a bile duct becomes permanently blocked. Bile then builds up inside the gallbladder, and the gallbladder can become infected and inflamed.

The medical term for this inflammation is acute cholecystitis. The symptoms are:

• pain in your upper abdomen that travels 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 1 in 7 people with acute cholecystitis also have jaundice (see below).

Doctors usually treat acute cholecystitis with antibiotics first, to settle the infection, and then with keyhole surgery to remove the gallbladder. The operation can be more difficult when it's done as an emergency, and there's a higher risk that it will have to be converted to an open procedure.

A severe infection can sometimes lead to a gallbladder abscess (empyema of the gallbladder). Antibiotics alone don't always clear these, and the abscess may need to be drained.

Occasionally a severely inflamed gallbladder can tear. This leads to peritonitis, which is inflammation of the inside lining of the abdomen. If it happens, you may need antibiotics given directly into a vein (intravenous antibiotics), and you may need surgery to remove a section of the lining if part of it is badly damaged.

Jaundice happens when a gallstone moves out of the gallbladder into the bile duct and blocks the flow of bile.

You may notice these symptoms:

• yellowing of the skin and eyes
• dark brown urine
• pale stools
• itching

Sometimes the stone passes out of the bile duct on its own. If it doesn't, it needs to be removed. The section on treating gallstones explains how.

When the bile ducts get blocked, bacteria can infect them. The medical term for a bile duct infection is acute cholangitis.

The symptoms of acute cholangitis include:

• pain in your upper abdomen that travels towards your shoulder blade
• a high temperature
• jaundice
• chills
• confusion
• itchy skin
• generally feeling unwell

Antibiotics will help treat the infection. But it's also important to help the bile from the liver drain, and this is done with a procedure called endoscopic retrograde cholangio-pancreatography (ERCP). The section on treating gallstones has more information.

Acute pancreatitis can develop when a gallstone moves out of the gallbladder and blocks the opening (duct) of the pancreas. This makes the pancreas inflamed.

The most common symptom is a sudden, severe, dull pain in the centre of your upper abdomen, around the top of your stomach.

The pain often gets steadily worse until it settles into a constant ache. The ache may travel from your abdomen along your back, and it may feel worse after you have eaten. Leaning forward or curling into a ball may help to ease it.

Other symptoms of acute pancreatitis can include:

• feeling sick
• being sick
• diarrhoea
• loss of appetite
• a high temperature (fever) of 38C (100.4F) or above
• tenderness of the abdomen
• less commonly, jaundice

There's currently no cure for acute pancreatitis, so treatment focuses on supporting the functions of the body until the inflammation has passed.

This usually means admission to hospital, where you can be given:

• fluids into a vein (intravenous fluids)
• pain relief
• nutritional support
• oxygen through tubes into your nose

With treatment, most people with acute pancreatitis improve within a week and are well enough to leave hospital after 5 to 10 days.

Gallbladder cancer is a rare but serious complication of gallstones. An estimated 660 cases are diagnosed in the UK each year.

If you've had gallstones, your risk of gallbladder cancer is higher. Approximately 4 out of every 5 people who have cancer of the gallbladder also have a history of gallstones. Even so, people with a history of gallstones have a less than one in 10,000 chance of developing it.

Some people have extra risk factors, such as a family history of gallbladder cancer or high levels of calcium inside the gallbladder. In that case, your doctor may recommend removing your gallbladder as a precaution, even if your gallstones aren't causing any 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

Treatment can be a combination of surgery, chemotherapy and radiotherapy.

Gallstone ileus is another rare but serious complication of gallstones. It happens when a gallstone blocks the bowel.

It can develop when an abnormal channel, called a fistula, opens up near the gallbladder. Gallstones can then travel through the fistula and get stuck in the bowel.

The symptoms of gallstone ileus include:

• abdominal pain
• being sick
• swelling of the abdomen
• constipation

A blocked bowel needs immediate medical treatment. Without it, the bowel could split open (rupture), which could cause internal bleeding and widespread infection.

If you suspect your bowel is blocked, contact your doctor as soon as possible.

Surgery is usually needed to remove the gallstone and clear the blockage. The type of surgery you have depends on where in the bowel the blockage is.

The evidence is limited, but changing your diet and losing weight (if you're overweight) may help prevent gallstones.

Cholesterol seems to play a part in how gallstones form, so it's sensible not to eat too many foods that are high in saturated fat.

Foods high in saturated fat include:

• meat pies
• sausages and fatty cuts of meat
• butter, ghee and lard
• cream
• hard cheeses
• cakes and biscuits
• food containing coconut or palm oil

A healthy, balanced diet is recommended. That means plenty of fresh fruit and vegetables (at least 5 portions a day) and wholegrains.

There's also evidence that eating nuts regularly, such as peanuts or cashews, can help reduce your risk of developing gallstones.

Drinking small amounts of alcohol may also help reduce your risk of gallstones. But you shouldn't regularly drink more than 14 units of alcohol a week, because this can lead to liver problems and other health conditions. Regularly drinking any amount of alcohol can increase the risk to your health.

Read more about:

• high cholesterol
• healthy eating

Being overweight, and especially being obese, raises the amount of cholesterol in your bile. That in turn raises your risk of developing gallstones. So try to keep your weight under control by eating a healthy diet and getting plenty of regular exercise.

But stay away from low-calorie, rapid-weight-loss diets. There's evidence they can disrupt your bile chemistry and add to your risk of gallstones. A more gradual weight loss plan is recommended.