Gallstones — Causes, Silent Stones, Biliary Colic & Cholecystectomy Guide — Symptoms, Causes & Treatment | MyMedicPlus

Gallstones (cholelithiasis) are solid deposits — calculi — that form in the gallbladder from imbalances in the chemical composition of bile. Approximately 10–15% of adults in Western countries have gallstones, with prevalence rising sharply with age. The majority (80%) of gallstones are asymptomatic and require no treatment. Symptomatic gallstones cause biliary colic (episodic severe right upper quadrant pain from temporary cystic duct obstruction), acute cholecystitis (gallbladder wall inflammation from sustained obstruction), choledocholithiasis (common bile duct stones), ascending cholangitis (biliary infection — medical emergency), and gallstone pancreatitis. Three types of gallstones exist: cholesterol stones (80% of cases in Western populations), pigment stones (black — from haemolysis; brown — from infection), and mixed stones. The natural history of gallstone disease is largely benign for asymptomatic incidentally discovered stones, but once biliary colic symptoms occur, the risk of serious complications increases substantially — emphasising the critical importance of early cholecystectomy after a first symptomatic episode to prevent life-threatening complications such as ascending cholangitis and gallstone pancreatitis.

Cholesterol gallstones form when bile becomes supersaturated with cholesterol, nucleating crystals that aggregate into stones. The 'five Fs' mnemonic captures classical risk factors: Female (oestrogen increases cholesterol secretion into bile), Fat (obesity — BMI above 30 increases risk 3-fold), Fertile (pregnancy — elevated oestrogen and progesterone impair gallbladder motility), Forty (age over 40), and Fair (Caucasian or Hispanic ethnicity — though also prevalent in South Asians). Additional risk factors: rapid weight loss or prolonged fasting (bile stasis), total parenteral nutrition (gallbladder stasis), diabetes mellitus, Crohn's disease (impaired bile acid reabsorption), haemolytic anaemias (pigment stones), cirrhosis, and use of fibrate drugs or octreotide. Genetics contribute 25–30% of gallstone risk.

Biliary colic: sudden-onset severe, constant (not truly colicky) right upper quadrant or epigastric pain, often radiating to the right shoulder or scapula, typically occurring 1–4 hours after a fatty meal, lasting 30 minutes to several hours before resolving spontaneously. Nausea and vomiting are common. Acute cholecystitis: severe, persistent right upper quadrant pain (lasting over 6 hours) with fever, nausea, vomiting, and a positive Murphy's sign (inspiratory arrest on deep palpation of the right upper quadrant). Choledocholithiasis (common bile duct stones): biliary colic plus obstructive jaundice (yellow skin and eyes), dark urine, pale stools, and itching. Ascending cholangitis (Charcot's triad — medical emergency): jaundice, fever with rigors, and severe right upper quadrant pain. Gallstone pancreatitis: epigastric pain radiating to the back, elevated serum amylase/lipase. Silent stones: no symptoms — incidental finding on imaging.

Abdominal ultrasound is the first-line investigation for suspected gallstones — sensitivity 97%, specificity 95% for gallbladder stones. It demonstrates hyperechoic foci with posterior acoustic shadowing, gallbladder wall thickening (above 4 mm in cholecystitis), and pericholecystic fluid. Blood tests: full blood count (leucocytosis in cholecystitis/cholangitis), liver function tests (elevated alkaline phosphatase, bilirubin, and GGT in choledocholithiasis), serum amylase and lipase (elevated in pancreatitis), and CRP (elevated in infection). Common bile duct stones: MRCP (magnetic resonance cholangiopancreatography) — non-invasive, high accuracy for ductal stones; endoscopic ultrasound (EUS) — equivalent sensitivity, allows simultaneous therapeutic ERCP if stones confirmed. CT scan: less sensitive for gallstones than USS but evaluates complications (perforation, abscess, pancreatitis). HIDA (hepato-iminodiacetic acid) scan: assesses gallbladder function when ultrasound is inconclusive.

Asymptomatic gallstones: no treatment required — annual risk of developing symptoms is approximately 2%; expectant management with dietary advice. Biliary colic: analgesia (diclofenac 75 mg IM or rectal — effective and reduces bile duct spasm; morphine also used), hydration, and elective laparoscopic cholecystectomy within 2–6 weeks to prevent recurrence and complications. Acute cholecystitis: IV antibiotics (co-amoxiclav or ciprofloxacin + metronidazole), IV fluids, analgesia, and early laparoscopic cholecystectomy within 72 hours of symptom onset (superior to delayed surgery). Choledocholithiasis: ERCP (endoscopic retrograde cholangiopancreatography) with sphincterotomy and stone extraction — clears the bile duct; followed by elective cholecystectomy. Ascending cholangitis: emergency IV antibiotics, urgent biliary decompression via ERCP — mortality without treatment is high. Gallstone pancreatitis: supportive management, nil-by-mouth, IV fluids; cholecystectomy during the same admission after recovery to prevent recurrence. Ursodeoxycholic acid (UDCA): oral dissolution therapy for small cholesterol stones in patients unfit for surgery — effective in only 30% and stones recur after stopping.

Symptomatic gallstone disease causes a spectrum of serious complications. Acute cholecystitis (inflamed gallbladder from sustained cystic duct obstruction) requires urgent surgery — delayed treatment risks gallbladder perforation, abscess, and empyema. Choledocholithiasis (common bile duct stones in 10-15% of gallstone patients) causes obstructive jaundice with elevated bilirubin, pale stools, and dark urine. Ascending cholangitis — Charcot's triad of fever, jaundice, and right upper quadrant pain — is a life-threatening biliary infection requiring emergency ERCP and IV antibiotics; without treatment, mortality approaches 100%. Gallstone pancreatitis occurs when a stone obstructs the common bile duct–pancreatic duct junction, triggering acute pancreatitis — ranging from mild self-limiting disease to severe necrotising pancreatitis with mortality up to 30-40%. Mirizzi syndrome: a large gallstone compresses the common hepatic duct causing jaundice. Gallbladder cancer, though rare (0.5% lifetime risk), is strongly associated with large stones above 3 cm and chronic gallstone disease. Without cholecystectomy after a first episode of biliary colic, 30% of patients develop a serious complication within 2 years.

Maintain a healthy body weight — obesity is the most important modifiable risk factor. Avoid rapid weight loss or crash dieting — lose weight gradually (no more than 0.5–1 kg per week). A low-fat, high-fibre diet (plenty of fruits, vegetables, wholegrains) reduces cholesterol supersaturation of bile. Regular physical activity (150 minutes of moderate exercise per week) reduces gallstone risk by 20–30%. Avoid prolonged fasting — maintain regular meals to promote gallbladder emptying. For patients undergoing rapid weight loss (bariatric surgery or very low-calorie diets), prophylactic ursodeoxycholic acid 500 mg twice daily during the weight loss phase significantly reduces gallstone formation. Do not delay cholecystectomy after a first episode of biliary colic — 30% of patients who delay surgery develop complications.

Seek emergency assessment immediately for: severe right upper quadrant or epigastric pain lasting more than 6 hours, fever with abdominal pain, jaundice (yellow eyes or skin), or rigors (severe shaking) — these may indicate acute cholecystitis, cholangitis, or gallstone pancreatitis, all of which require urgent hospital management. Attend your GP for: recurrent episodes of upper abdominal pain after fatty meals, nausea after eating, or indigestion not responding to antacids — gallstone disease is a common cause. If diagnosed with asymptomatic gallstones, discuss with your surgeon whether prophylactic cholecystectomy is appropriate given your age and comorbidities. Never ignore jaundice with abdominal pain and fever — ascending cholangitis can be rapidly fatal without emergency treatment.