GALLSTONES OVERVIEW

Gallstones are solid, pebble-like collections that form inside the gallbladder. The gallbladder is located in the upper right abdomen, under the liver (figure 1).

More than one million Americans are diagnosed with gallstones (cholelithiasis) every year, joining about 25 million who already have the disorder. Fortunately, most people with gallstones do not have symptoms and do not require treatment. In other cases, gallstones cause pain and must be treated by removing the stone(s) or the entire gallbladder.

More detailed information about gallstones is available by subscription. (See "Nonsurgical treatment of gallstone disease" and "Treatment of acute cholecystitis".)

THE GALLBLADDER

The gallbladder is a pear-shaped muscular organ that is 3 to 6 inches (7.5 to 15 cm) long, located in the right upper side of the abdomen, under the liver (figure 2). It is connected to the liver and intestine through small tubes called bile ducts (figure 1).

The primary purpose of the gallbladder is to store and concentrate bile, a greenish-brown fluid that is produced by the liver. Bile is needed to digest and absorb fatty foods, and to absorb important fat soluble vitamins.

Between meals, the gallbladder is relaxed and bile flows into the gallbladder, where it is stored and concentrated (figure 1). With meals, fatty foods in the small intestine cause the gallbladder to contract (squeeze). The gallbladder partially empties. A few hours later, the gallbladder relaxes and begins to store bile again.

WHAT ARE GALLSTONES?

Gallstones are collections of solid material that form inside the gallbladder. Gallstones may be as small as tiny specks or as large as the gallbladder itself. The vast majority, however, are smaller than 1 inch (2.5 cm) and are one of two major types, cholesterol or pigment. Gallstone type is important since cholesterol stones are more likely to respond to non-surgical treatments than pigment stones.

• Cholesterol gallstones account for approximately 80 percent of gallstones in developed countries, including the United States.
• Pigment stones account for about 20 percent of gallstones.

GALLSTONES RISK FACTORS

Experts do not for sure why gallstones develop. However, there are a number of factors that increase the risk of developing gallstones

• Sex — Gallstones are more common in women.
• Age — The risk of gallstones increases with age. The condition is extremely rare in children and becomes progressively more frequent over time, especially after age 40.
• Family history and genetics — Gallstones are more common in certain families, suggesting that genetics has a role in gallstone development.
• Other factors — Other conditions can increase the risk of developing gallstones, including:

• - Pregnancy
• - Use of medicines that contain estrogen (such as birth control pills)
• - Obesity
• - Frequent fasting
• - Rapid weight loss (including patients who have surgical weight loss treatments)
• - Lack of physical activity
• - Diabetes mellitus
• - Sickle cell disease (and other conditions associated with rapid destruction of red blood cells, such as in patients with mechanical heart valves)
• - Cirrhosis or severe scarring of the liver
• - Certain medicines

GALLSTONE SYMPTOMS

Silent gallstones — The majority of people who have gallstones do not have symptoms; their stones remain "silent." Silent gallstones are often found on an ultrasound or CT scan done for other reasons. Silent stones do not need to be treated since the first symptoms of gallstones are usually mild and there are risks involved in removing the gallbladder.

If you have silent gallstones, you should be aware of the initial symptoms of gallstone disease because you will need treatment quickly if you develop symptoms (see 'Biliary colic' below; the chance of worsening symptoms increases if treatment is delayed. (See "Approach to the patient with incidental gallstones".)

Biliary colic — Biliary colic, also known as gallstone pain or biliary pain, is the most common symptom of gallstones. It causes attacks of abdominal pain, often located in the right upper belly just under the lower ribs. You may also feel nausea, and vomiting, and pain in the right shoulder or back.

Biliary colic usually happens when the gallbladder contracts in response to a fatty meal. This compresses the stones, blocking the opening. As the gallbladder relaxes several hours after the meal, the pain subsides.

Once you have a first attack of biliary colic, there is a good chance you will have more severe symptoms in the future.

Acute cholecystitis — Acute cholecystitis refers to inflammation of the gallbladder. It happens when there is a complete blockage of the gallbladder, caused by repeated episodes of biliary colic. Unlike biliary colic, which resolves within a few hours, pain is constant with acute cholecystitis and fever is common.

Acute cholecystitis is a serious condition that requires immediate medical treatment in the hospital. Treatment includes IV fluids, pain medicine, and sometimes, antibiotics. Surgery to remove the gallbladder is usually recommended during the hospitalization or shortly thereafter. If not treated, acute cholecystitis can lead to gallbladder rupture, a life-threatening condition. (See "Treatment of acute cholecystitis".)

Complications of gallstones — Complications can develop if gallstones move and block the area where bile exits (a condition known as choledocholithiasis).

• Jaundice is a yellow discoloration of the skin and eyes.
• Acute cholangitis is an infection of the bile ducts that causes pain, chills, and fever. This requires prompt treatment, usually involving removal of the gallstone with a non-surgical procedure known as endoscopic retrograde cholangiopancreatography, or ERCP. (See "Patient information: ERCP (endoscopic retrograde cholangiopancreatography)".)
• Acute pancreatitis is sudden inflammation of the pancreas, leading to severe abdominal pain. (See "Patient information: Acute pancreatitis".)

GALLSTONE DIAGNOSIS

There are two parts to diagnosing gallstones: determining if gallstones are present, and determining if gallstones are the cause of symptoms.

Gallstones are usually found using ultrasound, a painless test that uses sound waves to create an image of the gallbladder. Gallstones can also be seen on other imaging tests.

Having gallstones does not mean that the gallstones are the cause of your symptoms. Thus, other tests may be recommended if there is doubt about the relationship of the gallstones to your symptoms.

GALLSTONE TREATMENT

There are three general options for people with gallstones; the best option depends upon your individual situation.

• Expectant management: Do nothing, wait and watch.
• Surgical therapy: Remove the gallbladder and stones.
• Non-surgical therapy: Eliminate the stones while preserving the gallbladder

Surgical treatment

Cholecystectomy — Cholecystectomy is a surgery that removes the gallbladder. It is one of the most commonly performed surgeries in the United States. The surgery is done in an operating room after you are given anesthesia.

The gallbladder is an important organ, but you can live without it. Removing the gallbladder does not usually cause serious complications. However, about half of people who have their gallbladder removed develop loose stools, gas, and bloating; in most people these symptoms are mild and do not require treatment.

Surgery may be done through an open incision (cut) in the skin. In most people, the surgery is done using small instruments and a video camera, which are inserted into the abdomen through several small puncture holes. This is called laparoscopic cholecystectomy.

Non-surgical treatments — Nonsurgical treatments are available for some people with gallstones. These treatments get rid of the gallstones while preserving the gallbladder. (See "Nonsurgical treatment of gallstone disease".)

Bile acid pill — A bile acid pill (ursodeoxycholic acid or ursodiol) is a medicine that can help to dissolve and break down gallstones. About two-thirds of people who take it become symptom free within two to three months after starting treatment. However, it may take several years for the stones to disappear completely. The treatment is safe and well tolerated. Some people develop mild, temporary diarrhea.

Because of its slow action, bile acid treatment is not practical in people who develop gallstone symptoms suddenly or if symptoms come back. Bile acid treatments are only used for people with small cholesterol stones and a functioning gallbladder. It is effective in eliminating stones in about 50 percent of people.

Extracorporeal shock wave lithotripsy — Extracorporeal shock wave lithotripsy (ESWL) uses shock waves to break gallstones into smaller fragments and "sand," which can then be dissolved more easily with an oral bile acid pill.

Lithotripsy is most effective in people with:

• Fewer than 3 stones
• Normal body weight (not obese)
• Good gallbladder function

The procedure may be uncomfortable, but a sedative or local anesthetic can be given to reduce discomfort. The procedure may cause attacks of biliary pain as fragments pass through the bile duct.

Since bile acid therapy is needed to clear the fractured stones and residue, lithotripsy can only treat cholesterol stones. The success of lithotripsy for gallstones varies, with experienced centers successfully treating 90 to 100 percent of people with one stone and up to 67 percent of people with two or three stones. (See "Endoscopic management of bile duct stones: Standard techniques and mechanical lithotripsy".)

Gallstone recurrence — The main disadvantage of the non-surgical treatment is that gallstones can come back. With bile acid treatment, stones come back in about 50 percent of people in the first five years. However, symptoms do not always come back and treatment is not always needed.

Gallstone prevention — The following treatments may be recommended to prevent gallstones from coming back after nonsurgical treatment:

• Eat three well-balanced meals daily, with each meal containing some fat to be sure that the gallbladder empties. This prevents bile from collecting in the gallbladder.
• Eat a diet that is high in fiber and calcium and low in saturated fats (fat that is solid at room temperature, such as butter, shortening, lard, meat fat).
• Try to stay at a healthy body weight by eating an appropriate number of calories and exercising for at least 30 minutes five days per week. If you are planning a rapid weight-loss program, such as weight loss surgery, your doctor or nurse should monitor you. Bile acids may be recommended to prevent gallstones from developing as you lose weight.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed every four months on our web site (www.uptodate.com/patients).

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information

Patient information: ERCP (endoscopic retrograde cholangiopancreatography)
Patient information: Acute pancreatitis

Professional level information

Approach to the patient with incidental gallstones
Clinical features and diagnosis of acute cholecystitis
Endoscopic management of bile duct stones: Standard techniques and mechanical lithotripsy
Epidemiology of and risk factors for gallstones
Gallbladder cancer: Epidemiology, risk factors, clinical features, and diagnosis
Nonsurgical treatment of gallstone disease
Patient selection for the nonsurgical treatment of gallstone disease
Treatment of acute cholecystitis
Uncomplicated gallstone disease

The following organizations also provide reliable health information.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/ency/article/000273.htm, available in Spanish)

• National Institutes Diabetes and Digestive and Kidney Diseases

      (http://digestive.niddk.nih.gov/ddiseases/pubs/gallstones/)

• The American Gastroenterological Association (AGA)

      (http://www.gastro.org/patient-center/digestive-conditions/gallstones)

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