Gallstones (Cholelithiasis)

What are gallstones?

The gallbladder is a small, pear-shaped organ that sits just beneath the liver on the right side of the abdomen. Its role is to store bile, a digestive fluid produced by the liver that helps the body break down and absorb fats. When a fatty meal is eaten, the gallbladder contracts and releases bile into the small intestine to assist with digestion.

Gallstones, known medically as biliary calculi or cholelithiasis, are solid masses that develop inside the gallbladder when certain components of bile become imbalanced and harden over time. They can range considerably in size, from particles no larger than a grain of sand to masses as large as a golf ball. A single large stone may develop, or the gallbladder may contain a combination of many smaller ones.

Bile is made up of water, cholesterol, fats, bile salts, proteins and bilirubin. When the proportions of these substances become disrupted, the conditions are created for stones to form. There are three recognised types: cholesterol stones, which develop when the liver produces excess cholesterol that crystallises within the bile; pigment stones, which are smaller and darker and arise when the gallbladder fails to empty properly or other bile components change; and mixed stones, which are the most common type and contain a combination of cholesterol and salts, often forming together in batches.

Gallstones become problematic when they shift out of the gallbladder and lodge within one of the bile ducts. These are the narrow channels responsible for transporting bile from the liver and gallbladder into the small intestine, including the hepatic ducts, the cystic duct and the common bile duct. A blockage in any of these pathways can obstruct the normal flow of bile and give rise to pain and other complications.

Who is most at risk of developing gallstones?

Gallstones affect a significant proportion of the population, with studies suggesting they can be found in up to 15 per cent of people aged 50 years and over. While there is no single identifiable cause, certain factors are associated with a higher likelihood of developing them.

Women are more commonly affected than men. The risk also increases with age, with people carrying excess body weight, and in those who experience rapid weight loss. A family history of gallstones raises an individual’s likelihood of developing them, as does having diabetes or taking certain medications such as triglyceride-lowering drugs known as fibrates. Pregnancy and the use of the oral contraceptive pill are additional factors that have been associated with gallstone formation.

Recognising the symptoms of gallstones

Many people with gallstones never experience any symptoms at all. In fact, approximately seven out of ten people with the condition remain unaware of it, and it is often detected incidentally during an ultrasound or scan performed for an unrelated purpose.

When symptoms do occur, the most common is pain in the upper abdomen or back, typically described as moderate to severe in intensity. This pain tends to be intermittent rather than constant and can worsen after consuming a fatty meal when the gallbladder contracts. Some people also notice increased abdominal discomfort following eating more generally.

It is worth noting that symptoms commonly attributed to gallstones, such as indigestion, bloating, nausea and intolerance of fatty foods, are not actually caused by gallstones and are unlikely to improve following gallbladder removal. Accurate diagnosis is therefore important before any decisions about treatment are made.
If you are experiencing persistent or severe abdominal pain, it is important to seek medical attention promptly.

Potential complications of gallstones

While most people with gallstones will never encounter a serious complication, those who carry stones over many years face a small but meaningful risk of developing further problems. Around one in ten people in this group will go on to develop jaundice, pancreatitis or an infection.
Complications arise when stones obstruct the bile ducts or trigger inflammation in surrounding structures, and most require prompt medical assessment. These can include the following.

Biliary colic occurs when a stone becomes lodged in the cystic duct, the narrow passage connecting the gallbladder to the common bile duct. This causes severe pain and can be accompanied by fever, though there is no inflammation of the gallbladder itself.

Cholecystitis is inflammation of the gallbladder, often associated with infection, and typically presents with pain, nausea and vomiting. This is a condition that requires hospital treatment, and if left unmanaged, carries the risk of the gallbladder rupturing.

Obstructive jaundice, also known as cholestasis, develops when a blockage in the bile ducts causes bilirubin to accumulate in the bloodstream. This results in a yellowing of the skin and the whites of the eyes and requires urgent medical attention.

Cholangitis is inflammation and infection of the bile duct itself, which can occur if the duct becomes obstructed and bacteria from the small intestine are able to enter.

Pancreatitis can arise when a stone at the lower end of the bile duct causes inflammation of the pancreas, producing significant and often severe pain.

Gallstone ileus, while less common, occurs when a stone passes into the intestine and causes a blockage within the small or large bowel.

Fever, jaundice, or pain that does not respond to simple pain relief and persists for several hours should be assessed urgently by a medical professional.

How are gallstones diagnosed?

The initial investigation for gallstones is an abdominal ultrasound. This is a non-invasive, painless test and is highly accurate at detecting stones within the gallbladder. Blood tests to assess liver function are also typically performed.

Where stones are suspected in the bile duct, or where complications are present, further investigations may be required. These can include a CT scan (computed tomography), an MRI scan (magnetic resonance imaging), or an MRCP (magnetic resonance cholangiopancreatography), which provides detailed imaging of the biliary system.

An EUS (endoscopic ultrasound) may be recommended in cases where stones in the bile duct are strongly suspected despite normal findings on other imaging. This involves passing a thin, flexible instrument fitted with an ultrasound probe into the digestive tract to obtain more detailed images.

In some situations, an ERCP (endoscopic retrograde cholangiopancreatography) is performed. This procedure uses an endoscope passed through the mouth, oesophagus, stomach and into the small bowel to visualise the bile duct directly. A thin tube is then passed through the endoscope into the bile duct, allowing x-rays to be taken and stones to be removed during the same procedure.

Your doctor will discuss which investigations are appropriate for your particular circumstances and may refer you to a gastroenterologist for specialist assessment.

Treatment options for gallstones

Not everyone with gallstones requires treatment. For those who are not experiencing symptoms, active management is often unnecessary, and a watchful approach may be recommended.

Where treatment is needed, the options depend on the location and behaviour of the stones and whether complications are present.

Dietary modification

Reducing the intake of fatty foods and full-fat dairy products may help to ease discomfort in people whose symptoms are related to gallbladder activity. Eating a varied diet with plenty of fruit and vegetables, maintaining adequate fluid intake and aiming for a gradual and sustainable approach to weight management where relevant can all support overall gallbladder health. A healthy diet will not dissolve existing stones, but it may reduce the frequency and severity of symptoms.

Medication

Certain medications can dissolve cholesterol-based gallstones. However, this approach is not widely recommended by specialists because the treatment is not consistently effective, can carry side effects, and stones frequently recur following its discontinuation.

Surgery

Surgical removal of the gallbladder, known as a cholecystectomy, is the most common and definitive treatment for symptomatic gallstones. The gallbladder is a non-essential organ, and its removal does not interfere with digestion. Following surgery, bile produced by the liver flows directly into the small intestine and continues to support the digestion of fats in the normal way.

The procedure is most commonly performed as laparoscopic or keyhole surgery, requiring three small incisions in the abdomen. A miniature camera and surgical instruments are guided through these openings to remove the gallbladder. Most patients require only one to two days in hospital following this approach.

In some circumstances, keyhole surgery is not suitable, and the gallbladder is removed through a larger incision beneath the right-sided ribs. This is referred to as open surgery and typically requires a hospital stay of five to eight days. As with all surgical procedures, there are small risks of intraoperative complications such as bleeding or bile duct injury, as well as post-operative concerns including chest infections. Your specialist will discuss these risks with you in detail before any procedure.

If stones are located within the bile duct rather than the gallbladder itself, an ERCP may be used to remove them. In some cases, x-rays taken during surgery reveal a stone in the bile duct that requires an ERCP to be performed at a later stage.
In specific situations involving large or difficult-to-remove stones, a technique called lithotripsy may be considered. This uses sound waves directed at the stones to break them into smaller fragments.

When is urgent treatment needed?

Complications such as jaundice, cholangitis or significant infection in the gallbladder or bile duct require prompt treatment in hospital. If you develop a fever, your skin or eyes become yellow, or you experience severe abdominal pain that does not settle, seek urgent medical attention.

Living well after gallbladder removal (cholecystectomy)

Many people are reassured to learn that a normal, healthy life is entirely possible following cholecystectomy. The liver continues to produce bile, which flows directly to the small intestine to assist with digestion. There is generally no requirement to follow a specific long-term diet after recovery, though individual responses may vary and your specialist will provide guidance suited to your situation. While stones can occasionally form in the bile duct even after the gallbladder has been removed, this is considerably less common.

When to see a gastroenterologist

If you have been referred to a specialist, or if you are experiencing ongoing abdominal pain, episodes of jaundice, or symptoms that are affecting your daily life, a gastroenterologist can provide a comprehensive assessment and guide you through the diagnostic and treatment process. Early specialist review helps to ensure that complications are identified promptly and that the most appropriate management pathway is determined for your individual circumstances.

To make an appointment with the team at Queensland Gastroenterology, please contact our rooms directly or send an appointment request.

This information has been sourced and adapted from education resources developed by GESA (Refer Our Website) and Health Direct Australia (Refer Our Website).