Gallstones

At a glance

  • Gallstones often go unnoticed.
  • But they sometimes lead to a cramping pain (colic) in the upper abdomen.
  • Colic increases the risk of complications like an inflammation of the gallbladder.
  • Surgery to remove the gallbladder is only needed if the symptoms keep coming back or there is a high risk of complications.

Introduction

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Gallbladder surgery is one of the most common operations in Germany. About 170,000 women and men have gallbladder surgery each year, mostly because they have gallstones that are causing symptoms or complications. But gallstones are often harmless, and a lot of people don't even notice that they have them. If the gallstones do cause problems, the main treatment options are medication to relieve the symptoms or surgery to remove the gallbladder.

Gallstones usually develop because there's too much cholesterol in the bile. The liver produces up to one liter of bile every day. It is used by the body to digest fats in the bowel. Most of the bile flows directly through the bile ducts into the duodenum (the first part of the small intestine) after you eat. Between meals, the rest of the bile is stored and concentrated in the gallbladder. The gallbladder is a pear-shaped, hollow organ, located on the right side of the abdomen, just below the liver.

Illustration: Location of the gallbladder – as described in the article

Location of gallbladder

Symptoms

A lot of people of have gallstones don't know about them because they don't have any symptoms, or only very general symptoms. Whether someone has symptoms and what kind of symptoms they have will depend on where the gallstones are (in the gallbladder or bile ducts), how big they are, and whether they are causing any complications.

Research has shown that about 2 to 4 out of 100 people with gallstones have noticeable symptoms within one year. About 50 out of 100 people who have already had symptoms like colic will get them again within two years.

The most typical sign of gallbladder stones (gallstones in the gallbladder) is very unpleasant, cramping pain in the upper abdomen (colic). Colic can arise if the gallstones are blocking the exit of the gallbladder or the opening of the bile duct (where it joins the duodenum). The pain comes in waves. It usually gets a bit better within an hour, eventually disappearing completely a few hours later. Sometimes it radiates into your right shoulder and your back.

Cramping pain in the upper abdomen can also be caused by a different condition known as bile duct stones. These may lead to jaundice (sometimes called icterus) too – a condition where the skin and the eyes take on a yellowish color. Here the jaundice is caused by bile duct stones preventing proper bile drainage. The bile pigment (bilirubin) that is made in the liver is no longer able to flow out, which raises the level of yellow bilirubin in the blood, causing the discoloration. This may also make urine (pee) darker, and stool (poop) may have a lighter color.

People who have gallstones sometimes also have general symptoms such as nausea, vomiting and feeling full.

Illustration: Gallstones – as described in the article

Gallstones in the gallbladder and common bile duct

Causes

Bile is made up of water and several other substances, some of which do not dissolve in water. If these substances clump together, gallstones form. Most gallstones are made of cholesterol. Other, less common, types of gallstones are known as pigment stones. They consist of and bilirubin. Bilirubin is a yellowish pigment that is made when the hemoglobin in red blood cells is broken down.

Gallstones can form in the gallbladder itself and, less frequently, directly in the bile ducts. Most bile duct stones first form in the gallbladder and then migrate into the common bile duct (ductus choledochus). The medical term for gallstones in the gallbladder is cholecystolithiasis, and the medical term for gallstones in the bile ducts is choledocholithiasis.

Risk factors

The following factors are known to increase the risk of gallstones:

  • Age: The risk of developing gallstones increases with age, especially after you reach the age of 40.
  • Genes: If several people in your family have had gallstones.
  • Sex: Women are more likely to get gallstones than men. Female sex are believed to increase the risk of gallstones.
  • Pregnancy.
  • Using the contraceptive pill or estrogen tablets during menopause (hormone therapy).
  • Functional problems of the gallbladder: The organ can't contract (squeeze bile out) properly, increasing the risk of stones forming.
  • Short bowel syndrome: A disorder that can develop after surgical removal of a large segment of the .
  • Diabetes.
  • Cirrhosis: A severe liver disease that is sometimes caused by drinking too much alcohol.
  • Being very overweight.
  • Losing a lot of weight in a short time: This happens a lot in very overweight people who have surgery to make their stomach smaller.
  • Special high-calorie liquid food.
  • Hemolysis: A disease that causes more red blood cells to be broken down.

Prevalence

It is estimated that between 5 and 25% of the population have gallstones. They are more common in older people and women. But they usually don't cause any symptoms.

Effects

If the typical symptoms arise, there is a greater risk of complications, such as of the gallbladder or pancreas. About 0.2 % of people with gallstones develop complications each year.

Diagnosis

Gallstones are sometimes found by chance, for example during an ultrasound scan of the abdomen. But the doctor will often specifically look for them because you have symptoms that could be signs of gallstones. Before any diagnostic tests are done, it's important to describe your symptoms to the doctor in detail.

Diagnosing gallstones in the gallbladder is normally quite straightforward. After you have talked to the doctor, you will have a physical examination and an ultrasound scan of your abdomen. This will usually be enough to make a . More tests may be needed to make sure the symptoms aren't being caused by other medical problems.

Diagnosing gallstones located in the bile duct may be more complicated. If there is reason to believe you might have bile duct stones, an ultrasound scan will usually be done here too. But bile duct stones are more difficult to detect on an ultrasound image. Because of this, you might then have a special x-ray examination called endoscopic retrograde cholangiography (ERC). This involves inserting an through the mouth and gently pushing it along the food pipe, stomach and into the duodenum, where the bile duct opening is found. The doctor will then inject a contrast agent (a dye-like substance) into the duct so that any stones become visible on the x-ray image. The can also be used to remove stones during the procedure.

Other options include magnetic resonance cholangiography (MRC) and endoscopic ultrasound (EUS, or endosonography). MRC produces cross-sectional images of the bile duct system. Radiation isn't used in MRC or EUS. MRC doesn't need to be done with an . This means that, unlike with ERC, any stones that are discovered can't be removed during the examination. This would have to be done in a separate procedure.

Treatment

If gallstones don't cause any problems, then there's usually no need to treat them. A lot of people with gallstones don't have any symptoms for a long time. What's more, any treatment can have side effects, and surgery always carries certain risks.

People who have very large gallstones in their gallbladder or specific types of porcelain gallbladder (calcification of the gallbladder wall) are at greater risk of developing gallbladder cancer. Surgical removal of the gallbladder is usually recommended for the treatment of porcelain gallbladder, even if there are no symptoms.

Various painkillers and antispasmodic medications are available for the relief of painful colic. Symptoms like bloating or nausea can also be treated with medicine. Drugs that can dissolve the gallstones are only rarely used.

Removing the gallbladder is the only way to permanently prevent painful colic and complications. Whether and when this step is taken will depend on several factors, including the severity of symptoms and the risk of complications.

Further information

When people are ill or need medical advice, they usually go to see their family doctor first. Read about how to find the right doctor, how to prepare for the appointment and what to remember.

Brazzelli M, Cruickshank M, Kilonzo M et al. Clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones or cholecystitis: a systematic review and economic evaluation. Health Technol Assess 2014; 18(55): 1-101, v-vi.

Deutsche Gesellschaft für Verdauungs- und Stoffwechselerkrankungen (DGVS), Deutsche Gesellschaft für Viszeralchirurgie (DGVC). Diagnostik und Therapie von Gallensteinen. S3-Leitlinie. July 2007. (AWMF-Leitlinien; volume 021 - 008).

Fraquelli M, Casazza G, Conte D et al. Non-steroid anti-inflammatory drugs for biliary colic. Cochrane Database Syst Rev 2016; (9): CD006390.

Gurusamy KS, Davidson BR. Gallstones. BMJ 2014; 348: g2669.

Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen (AQUA). 12/1 - Cholezystektomie. Qualitätsindikatoren: Bundesauswertung zum Erfassungsjahr 2014. 2015.

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

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Updated on April 27, 2021
Next planned update: 2024

Authors/Publishers:

Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

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