Gallstones — Causes, Symptoms, Diagnosis & Treatment Guide — Symptoms, Causes & Treatment | MyMedicPlus

Gallstones (cholelithiasis) are solid deposits that form in the gallbladder when bile becomes supersaturated with cholesterol, calcium bilirubinate, or both. They are extremely common, affecting 10-15% of adults in Western countries and over 20% of women over 60. Approximately 75% of gallstones are cholesterol stones (formed when bile contains excess cholesterol relative to bile salts and lecithin); 25% are pigment stones (black pigment — chronic haemolysis; brown pigment — infection, ductal stasis). Most gallstones are asymptomatic ('silent gallstones') and discovered incidentally. When stones obstruct the cystic duct or bile duct, they cause biliary colic, acute cholecystitis, common bile duct (CBD) obstruction causing obstructive jaundice and cholangitis, or acute pancreatitis — all requiring specific medical or surgical management. The rising global prevalence of gallstone disease is directly linked to the obesity epidemic, as increased cholesterol secretion into bile relative to bile salts and phospholipids creates lithogenic bile; gallstone disease is now the most common elective general surgical indication in high-income countries.

Cholesterol gallstones form when bile is supersaturated with cholesterol — from excess hepatic cholesterol secretion, impaired bile salt secretion, or reduced gallbladder contractility allowing bile stasis. Classic risk factors summarised as 'Fat, Female, Fertile, Forty, Fair': obesity (BMI above 30 — gallstone risk 3x higher), female sex (oestrogen increases cholesterol secretion and reduces gallbladder motility — progesterone also promotes stasis), pregnancy and multiparity, age over 40, and Caucasian/Hispanic ethnicity. Additional risk factors: rapid weight loss or prolonged fasting (impaired gallbladder contractility), hyperlipidaemia, type 2 diabetes, ileal disease or resection (reduces bile salt reabsorption — Crohn's disease), total parenteral nutrition (TPN), haemolytic anaemia (sickle cell disease, hereditary spherocytosis — black pigment stones from chronic haemolysis), and family history of gallstones. OCPs containing oestrogen increase gallstone risk.

Asymptomatic gallstones (most common): discovered incidentally on abdominal ultrasound — approximately 80% remain asymptomatic indefinitely and do not require treatment. Biliary colic: sudden severe right upper quadrant or epigastric pain, typically occurring 30-90 minutes after a fatty meal as gallbladder contracts against an obstructed cystic duct; pain is constant (not truly colicky despite the name), radiating to the right shoulder or scapula, lasting 1-5 hours, associated with nausea and vomiting. Acute cholecystitis: sustained right upper quadrant pain, fever, positive Murphy's sign (arrest of inspiration on deep palpation of RUQ), elevated white cell count and CRP — from prolonged cystic duct obstruction with secondary inflammation/infection. Choledocholithiasis (CBD stone): obstructive jaundice (yellow skin/eyes, dark urine, pale stools), pruritus. Ascending cholangitis (Charcot's triad): fever, jaundice, and right upper quadrant pain — septic emergency. Gallstone pancreatitis: acute epigastric pain radiating to the back, elevated amylase/lipase.

Abdominal ultrasound is the first-line investigation: highly sensitive (95%) and specific (99%) for gallbladder stones, detecting stones as small as 2 mm; also assesses gallbladder wall thickness, pericholecystic fluid (cholecystitis), and bile duct dilation. Blood tests: FBC (leucocytosis in cholecystitis, cholangitis), LFTs (elevated bilirubin and ALP in biliary obstruction; elevated transaminases in cholangitis or gallstone pancreatitis), amylase/lipase (pancreatitis), blood cultures (cholangitis). CT abdomen: useful for complications (perforation, abscess, pancreatitis severity); less sensitive than ultrasound for uncomplicated gallstones. MRCP (magnetic resonance cholangiopancreatography): non-invasive gold-standard imaging for common bile duct stones and biliary anatomy — preferred before ERCP. ERCP (endoscopic retrograde cholangiopancreatography): therapeutic procedure for CBD stone extraction via sphincterotomy and balloon sweeping. Endoscopic ultrasound (EUS): highly sensitive for small CBD stones not detected on MRCP.

Asymptomatic gallstones: no treatment required for most patients. Prophylactic cholecystectomy is considered in specific circumstances: sickle cell disease, porcelain gallbladder (calcified gallbladder wall), very large stones above 3 cm (increased gallbladder cancer risk), immunosuppressed patients. Symptomatic gallstones: laparoscopic cholecystectomy is the gold standard — minimally invasive, performed as a day case or short stay, with 5% conversion to open surgery. Ideally performed within 7 days of acute cholecystitis presentation (early laparoscopic cholecystectomy is superior to interval surgery — reduces recurrent events and hospital stay). Acute cholecystitis: IV antibiotics (piperacillin-tazobactam or co-amoxiclav), analgesia, and early laparoscopic cholecystectomy. Common bile duct stones: ERCP with sphincterotomy and stone extraction before or after cholecystectomy. Ascending cholangitis: emergency ERCP for biliary drainage — life-saving; blood cultures and broad-spectrum IV antibiotics. Gallstone pancreatitis: supportive care, ERCP if ascending cholangitis, cholecystectomy before discharge to prevent recurrence.

Most gallstones remain asymptomatic, but symptomatic or complicated gallstone disease carries significant morbidity. Acute cholecystitis — occurring in 20% of symptomatic gallstone patients — presents with severe right upper quadrant pain, fever, Murphy's sign, and leucocytosis; it may progress to gangrenous cholecystitis, gallbladder empyema, or perforation causing bile peritonitis, which is life-threatening. Acute cholangitis (Charcot's triad: fever, rigors, and jaundice) results from bile duct stone obstruction and bacterial infection ascending the biliary tree — Reynold's pentad (adding hypotension and confusion) indicates severe suppurative cholangitis requiring emergency biliary decompression by ERCP and IV antibiotics; mortality without drainage is approximately 100%. Acute pancreatitis from gallstone passage into the pancreatic duct (gallstone pancreatitis) — the most common cause of pancreatitis in women — can be severe (Revised Atlanta Classification severe, with infected pancreatic necrosis) carrying mortality of 30-40%. Mirizzi syndrome — external compression of the common hepatic duct by a large impacted cystic duct stone — causes obstructive jaundice and cholangitis. Choledocholithiasis (common bile duct stones) in approximately 10% of cholecystitis patients. Gallbladder carcinoma, though rare, is associated with longstanding large gallstones (greater than 3 cm diameter) and porcelain gallbladder — with 5-year survival below 5% for advanced disease.

Avoid rapid weight loss: crash diets and very low-calorie diets (below 800 kcal/day) significantly increase gallstone formation by reducing gallbladder motility and increasing cholesterol saturation of bile. Ursodeoxycholic acid (UDCA) 300 mg twice daily can be prescribed prophylactically during rapid weight loss programs (bariatric surgery) to reduce gallstone formation risk. Maintain healthy weight through gradual, sustained lifestyle modification rather than extreme dieting. Physical activity reduces gallstone risk by 20-40%. Eat a high-fibre, low-fat diet with regular meals — prolonged fasting increases gallstone risk. Reduce saturated fat and refined carbohydrate intake. Coffee consumption (4+ cups/day) is associated with reduced gallstone risk. Women at high risk should discuss the risk-benefit balance of oestrogen-containing contraception with their doctor.

Seek emergency care immediately for: severe right upper quadrant pain with fever (acute cholecystitis), jaundice with fever and rigors (ascending cholangitis — septic emergency requiring urgent ERCP), severe upper abdominal pain radiating to the back with vomiting (acute pancreatitis). Ascending cholangitis is a life-threatening emergency with mortality of up to 30% without urgent biliary drainage. See a doctor promptly for a first episode of biliary colic (to confirm the diagnosis with ultrasound and plan management), new jaundice, or worsening abdominal pain. Asymptomatic gallstones discovered incidentally should be discussed with your GP — most do not require treatment, but the findings need to be documented and symptoms reviewed at future consultations.