Gallstones (Cholelithiasis)
Summary
Gallstones are solid deposits that form in the gallbladder, affecting approximately 10-15% of Western populations. The majority are cholesterol stones (80%), with the remainder being pigment or mixed stones. Most gallstones are asymptomatic and discovered incidentally. When symptomatic, they cause biliary colic — episodic right upper quadrant pain triggered by fatty meals. Complications include acute cholecystitis, choledocholithiasis (CBD stones), ascending cholangitis, and gallstone pancreatitis. Treatment of symptomatic gallstones is laparoscopic cholecystectomy.
Key Facts
- Definition: Solid deposits (cholesterol or pigment) forming in gallbladder
- Prevalence: 10-15% in Western populations; most asymptomatic
- Risk Factors: The 6 F's — Fat, Female, Forty, Fertile, Fair, Family
- Symptom: Biliary colic — RUQ pain after fatty meals, lasting 1-5 hours
- Investigation: Abdominal ultrasound (first-line, 95% sensitivity)
- Treatment: Symptomatic → laparoscopic cholecystectomy
Clinical Pearls
"The 6 F's": Fat, Female, Forty, Fertile (pregnancy/OCP), Fair (Caucasian), Family history. Classic risk factor mnemonic, though stones occur in all demographics.
"Pain >24 Hours = Not Biliary Colic": True biliary colic resolves within 1-5 hours. Pain lasting >24 hours suggests acute cholecystitis or other complication — look for fever and peritonism.
Charcot's Triad: Fever + Jaundice + RUQ pain = ascending cholangitis. Add altered consciousness + hypotension = Reynolds' pentad (severe). This is a surgical emergency.
Why This Matters Clinically
Gallstones are extremely common. Most are asymptomatic and require no treatment. However, complications are potentially life-threatening — acute cholecystitis, cholangitis, and pancreatitis require urgent intervention. Recognising the difference between uncomplicated biliary colic and dangerous complications is essential.
Incidence & Prevalence
- Prevalence: 10-15% in Western populations; 20-25% in those >60 years
- Symptomatic: Only ~20% become symptomatic
- Global Variation: Higher in Western/developed countries, lower in Africa
Demographics
| Factor | Details |
|---|---|
| Age | Increases with age; peak >40 years |
| Sex | Female:Male 2-3:1 (premenopausal); equalises post-menopause |
| Ethnicity | Higher in Native Americans, lower in African populations |
| Trend | Increasing with obesity epidemic |
Risk Factors (The 6 F's)
| Risk Factor | Mechanism |
|---|---|
| Fat (Obesity) | Increased cholesterol secretion in bile |
| Female | Oestrogen increases cholesterol secretion; progesterone impairs gallbladder motility |
| Forty (Age >40) | Biliary cholesterol increases with age |
| Fertile (Pregnancy, OCP, HRT) | Hormonal effects on bile composition and motility |
| Fair (Caucasian, Native American) | Genetic predisposition |
| Family (First-degree relative) | Genetic factors |
Additional Risk Factors:
- Rapid weight loss, bariatric surgery
- TPN (reduces gallbladder contractility)
- Crohn's disease (ileal resection — bile salt malabsorption)
- Haemolytic disorders (pigment stones)
- Cirrhosis
- Drugs (fibrates, somatostatin analogues)
Mechanism (Cholesterol Stones — 80%)
Step 1: Cholesterol Supersaturation
- Bile contains cholesterol, phospholipids, and bile acids
- If cholesterol exceeds solubilising capacity → supersaturation
Step 2: Nucleation
- Cholesterol crystals precipitate
- Pro-nucleating factors (mucin, glycoproteins) promote crystal formation
Step 3: Gallbladder Hypomotility
- Impaired contractility (pregnancy, fasting, TPN)
- Allows crystals to aggregate and grow
Step 4: Stone Formation
- Progressive accumulation of cholesterol layers
- Stones can range from sand-like sludge to large single stones
Types of Gallstones
| Type | Composition | Proportion | Risk Factors |
|---|---|---|---|
| Cholesterol | >50% cholesterol | 75-80% | Obesity, metabolic syndrome |
| Pigment (Black) | Calcium bilirubinate | 10-25% | Haemolysis, cirrhosis |
| Pigment (Brown) | Calcium bilirubinate + bacteria | 5% | Biliary infection, stasis |
| Mixed | Cholesterol + pigment | Variable | Combination of factors |
Anatomical Considerations
- Cystic Duct: Connects gallbladder to CBD; stone impaction here causes biliary colic/cholecystitis
- CBD: Stone passage/impaction causes choledocholithiasis, jaundice
- Ampulla of Vater: Stone impaction can cause both cholangitis and pancreatitis
Symptoms (Spectrum)
Asymptomatic (80%)
Biliary Colic (Symptomatic Uncomplicated)
Acute Cholecystitis
Choledocholithiasis (CBD Stone)
Ascending Cholangitis
Signs
| Condition | Signs |
|---|---|
| Biliary colic | May be entirely normal between episodes; mild RUQ tenderness during attack |
| Acute cholecystitis | Fever, RUQ tenderness, Murphy's sign positive, guarding |
| Cholangitis | Fever, jaundice, RUQ tenderness, sepsis signs |
| Pancreatitis | Epigastric tenderness, may have Grey-Turner or Cullen signs (severe) |
Red Flags
[!CAUTION] Red Flags — Require urgent/emergency intervention:
- Fever + RUQ pain + jaundice (cholangitis — emergency)
- Pain >24 hours with fever + tachycardia (cholecystitis)
- Signs of sepsis or shock
- Generalised peritonitis (perforation)
- Epigastric pain + elevated amylase (pancreatitis)
Structured Approach
General:
- Vital signs (fever, tachycardia, hypotension = sepsis concern)
- Jaundice
- Hydration status
Abdominal Examination:
- Inspection: Jaundice, scars
- Palpation: RUQ tenderness, Murphy's sign, mass (mucocoele)
- Peritonism: Guarding, rebound (suggests perforation/peritonitis)
Special Tests
| Test | Technique | Positive Finding | Significance |
|---|---|---|---|
| Murphy's Sign | Deep palpation in RUQ during inspiration | Catches breath due to pain | Acute cholecystitis (90% sensitive in ultrasound-confirmed cases) |
| Boas' Sign | Hyperaesthesia below right scapula | Referred pain | Gallbladder disease |
| Courvoisier's Sign | Palpable non-tender gallbladder + jaundice | Obstructive jaundice NOT from stones | Suggests malignant obstruction (pancreatic head cancer) |
First-Line
| Test | Expected Finding | Notes |
|---|---|---|
| Abdominal USS | Gallstones, wall thickening, CBD dilatation | First-line; 95% sensitivity for gallstones |
| FBC | Leukocytosis (cholecystitis/cholangitis) | Raised WCC suggests inflammation |
| LFTs | Raised ALP/GGT if CBD stone; raised bilirubin if obstructed | "Obstructive" pattern |
| Amylase/Lipase | Raised if pancreatitis | >3x upper limit diagnostic |
| CRP | Raised in inflammation | Correlates with severity |
Further Imaging
| Modality | Indication | Findings |
|---|---|---|
| MRCP | Suspected CBD stone; pre-ERCP planning | Non-invasive CBD visualisation |
| CT Abdomen | Unclear diagnosis, complications | Cholecystitis complications, perforation, abscess |
| HIDA Scan | Equivocal USS; ? acute cholecystitis | Non-filling = cystic duct obstruction |
| ERCP | Therapeutic — CBD stone removal | Not purely diagnostic now |
| EUS | If MRCP inconclusive | Very sensitive for small CBD stones |
Diagnostic Criteria
Biliary Colic:
- Episodic RUQ pain + gallstones on USS + no signs of complications
Acute Cholecystitis (Tokyo Guidelines):
- A: Local signs (Murphy's sign, RUQ mass/tenderness)
- B: Systemic signs (fever, raised WCC, raised CRP)
- C: Imaging confirmation (USS or CT)
- Definite = A + B + C; Suspected = A + B
Management Algorithm
GALLSTONES MANAGEMENT
↓
┌─────────────────────────────────────────────────────┐
│ ASYMPTOMATIC GALLSTONES │
│ │
│ • No treatment required │
│ • Patient education on symptoms to watch for │
│ • Annual symptomatic risk: 2-4% │
│ │
│ Exceptions requiring cholecystectomy: │
│ • Porcelain gallbladder (cancer risk) │
│ • Large stones (>3cm — increased cancer risk) │
│ • Gallbladder polyp + stones │
└─────────────────────────────────────────────────────┘
↓
┌─────────────────────────────────────────────────────┐
│ BILIARY COLIC │
│ │
│ Acute: │
│ • NSAIDs (diclofenac 75mg IM) — first-line │
│ • Opioids if NSAIDs insufficient │
│ • Anti-emetics │
│ │
│ Definitive: │
│ • Elective laparoscopic cholecystectomy │
│ • Reduces recurrence and complications │
└─────────────────────────────────────────────────────┘
↓
┌─────────────────────────────────────────────────────┐
│ ACUTE CHOLECYSTITIS │
│ │
│ • Nil by mouth, IV fluids, analgesia │
│ • IV antibiotics (co-amoxiclav or cefuroxime + metro)│
│ • Early cholecystectomy (within 72 hours if possible)│
│ - Index admission surgery preferred │
│ - Delayed (6-8 weeks) if severe comorbidity │
│ • Percutaneous cholecystostomy if unfit for surgery │
└─────────────────────────────────────────────────────┘
↓
┌─────────────────────────────────────────────────────┐
│ CBD STONE (Choledocholithiasis) │
│ │
│ • MRCP to confirm │
│ • ERCP + sphincterotomy + stone extraction │
│ • Then laparoscopic cholecystectomy (same admission)│
│ OR │
│ • Laparoscopic cholecystectomy + intraoperative │
│ cholangiography + laparoscopic CBD exploration │
└─────────────────────────────────────────────────────┘
↓
┌─────────────────────────────────────────────────────┐
│ ASCENDING CHOLANGITIS │
│ │
│ EMERGENCY: │
│ • Resuscitation (fluids, antibiotics, ITU if septic)│
│ • IV antibiotics (broad spectrum) │
│ • Urgent ERCP for biliary drainage (within 24-48h) │
│ • Percutaneous drainage if ERCP fails │
│ • Cholecystectomy after recovery │
└─────────────────────────────────────────────────────┘
↓
┌─────────────────────────────────────────────────────┐
│ GALLSTONE PANCREATITIS │
│ │
│ • Supportive care (fluids, analgesia, NBM initially)│
│ • ERCP if cholangitis or persistent CBD obstruction │
│ • Cholecystectomy on SAME ADMISSION (NICE guidance) │
│ - Prevents recurrence │
│ • If severe pancreatitis: delay until resolved │
└─────────────────────────────────────────────────────┘
Surgical Management
Laparoscopic Cholecystectomy:
- Gold standard for symptomatic gallstones
- Day case or overnight stay in most cases
- Conversion rate to open: ~5%
- Complications: Bile duct injury (0.3-0.5%), bleeding, bile leak
Timing:
- Biliary colic: Elective (within weeks)
- Acute cholecystitis: Early (within 72 hours preferred) or delayed (6-8 weeks)
- Gallstone pancreatitis: Same admission (NICE) or within 2 weeks
Complications of Gallstones
| Complication | Presentation | Management |
|---|---|---|
| Acute Cholecystitis | RUQ pain, fever, Murphy's | Antibiotics, cholecystectomy |
| Choledocholithiasis | Jaundice, RUQ pain | ERCP + cholecystectomy |
| Ascending Cholangitis | Charcot's triad | Emergency ERCP |
| Gallstone Pancreatitis | Epigastric pain, raised lipase | Supportive, ERCP if obstructed |
| Gallbladder Empyema | Sepsis, RUQ mass | Urgent cholecystectomy/drainage |
| Gallbladder Perforation | Peritonitis | Emergency surgery |
| Mirizzi Syndrome | CBD obstruction by impacted cystic duct stone | Surgical |
| Gallstone Ileus | Small bowel obstruction (fistula to duodenum) | Surgery |
Surgical Complications
- Bile duct injury (0.3-0.5%) — serious
- Bleeding
- Bile leak (cystic duct stump)
- Post-cholecystectomy syndrome (persistent symptoms)
- CBD stones (undetected at surgery)
Natural History
Most gallstones remain asymptomatic. Annual risk of symptoms developing is 2-4%. Once symptomatic, recurrence is common, and complications become more likely over time, hence the recommendation for cholecystectomy.
Outcomes with Treatment
| Variable | Outcome |
|---|---|
| Laparoscopic cholecystectomy | 95% symptom resolution |
| Post-cholecystectomy syndrome | 10-40% (usually mild) |
| Mortality (elective cholecystectomy) | <0.1% |
| Mortality (acute cholecystitis) | 1-3% (higher if delayed) |
| Mortality (cholangitis with sepsis) | 10-20% if untreated |
Key Guidelines
-
NICE CG188: Gallstone Disease (2014) — Recommends early surgery for acute cholecystitis and same-admission cholecystectomy for gallstone pancreatitis.
-
Tokyo Guidelines (2018) — Diagnostic criteria and severity grading for acute cholecystitis and cholangitis.
Landmark Trials
CHOCOLITE Trial (Expected 2024) — Comparing early vs delayed cholecystectomy in acute cholecystitis; results pending.
Gutt et al. (2013) — RCT early vs delayed cholecystectomy in mild gallstone pancreatitis
- Key finding: Same-admission cholecystectomy reduced recurrence without increased complications
- Clinical Impact: Established same-admission cholecystectomy as standard
Evidence Strength
| Intervention | Level | Key Evidence |
|---|---|---|
| Cholecystectomy for symptomatic stones | 1a | Systematic reviews |
| Early cholecystectomy (acute cholecystitis) | 1b | RCTs |
| Same-admission cholecystectomy (pancreatitis) | 1b | RCTs, NICE guidance |
| ERCP for cholangitis | 2a | Cohort studies, NICE |
What are Gallstones?
Gallstones are hard deposits that form in your gallbladder — a small organ under your liver that stores bile. They range in size from tiny grains to golf balls. Most are made of cholesterol. Many people have gallstones without ever knowing.
Why does it matter?
Most gallstones cause no problems. However, if a stone blocks the drainage of your gallbladder, it can cause:
- Biliary colic: Intense pain in the upper right abdomen, usually after eating fatty foods
- Cholecystitis: An infected, inflamed gallbladder (more serious)
- Blockage of the bile duct: This can cause jaundice (yellow skin) and serious infection
How is it treated?
-
No symptoms: If gallstones aren't causing problems, you don't need treatment. Many people live with them without any issues.
-
Symptoms (biliary colic): The best treatment is keyhole surgery to remove the gallbladder (laparoscopic cholecystectomy). You can live perfectly normally without a gallbladder — the body adapts.
-
Serious complications: These need hospital admission, antibiotics, and sometimes emergency procedures to clear blockages.
What to expect after surgery
- Most people go home the same day or next day
- Full recovery in 1-2 weeks
- You can eat normally — your liver still makes bile
- Some people have loose stools initially (temporary)
When to seek help
See a doctor urgently if you have:
- Severe pain that won't go away
- Fever with abdominal pain
- Yellow skin or eyes (jaundice)
- Vomiting with inability to keep fluids down
Primary Guidelines
-
National Institute for Health and Care Excellence. Gallstone disease: diagnosis and management (CG188). 2014. nice.org.uk/guidance/cg188
-
Yokoe M, Hata J, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):41-54. PMID: 29032636
Key Trials
-
Gutt CN, Encke J, Köninger J, et al. Acute cholecystitis: early versus delayed cholecystectomy: a multicenter randomized trial. Ann Surg. 2013;258(3):385-393. PMID: 24022431
-
van Baal MC, Besselink MG, Bakker OJ, et al. Timing of cholecystectomy after mild biliary pancreatitis: a systematic review. Ann Surg. 2012;255(5):860-866. PMID: 22470079
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate guidelines and specialists for patient care.