Gallstones

Gallstones are hard particles that develop in the gallbladder. The gallbladder is a small, pear-shaped organ located in the upper right abdomen—the area between the chest and hips—below the liver.

Gallstones can range in size from a grain of sand to a golf ball. The gallbladder can develop a single large gallstone, hundreds of tiny stones, or both small and large stones. Gallstones can cause sudden pain in the upper right abdomen. This pain, called a gallbladder attack or biliary colic, occurs when gallstones block the ducts of the biliary tract.

Certain people have a higher risk of developing gallstones than others:2

• Women are more likely to develop gallstones than men. Extra estrogen can increase cholesterol levels in bile and decrease gallbladder contractions, which may cause gallstones to form. Women may have extra estrogen due to pregnancy, hormone replacement therapy, or birth control pills.
  
• People over age 40 are more likely to develop gallstones than younger people.
  
• People with a family history of gallstones have a higher risk.
  
• American Indians have genetic factors that increase the amount of cholesterol in their bile. In fact, American Indians have the highest rate of gallstones in the United States—almost 65 percent of women and 30 percent of men have gallstones.
  
• Mexican Americans are at higher risk of developing gallstones.
  

Other factors that affect a person’s risk of gallstones include2

• Obesity. People who are obese, especially women, have increased risk of developing gallstones. Obesity increases the amount of cholesterol in bile, which can cause stone formation.
  
• Rapid weight loss. As the body breaks down fat during prolonged fasting and rapid weight loss, the liver secretes extra cholesterol into bile. Rapid weight loss can also prevent the gallbladder from emptying properly. Low-calorie diets and bariatric surgery—surgery that limits the amount of food a person can eat or digest—lead to rapid weight loss and increased risk of gallstones.
  
• Diet. Research suggests diets high in calories and refi_ned carbohydrates and low in fi_ber increase the risk of gallstones. Refi_ned carbohydrates are grains processed to remove bran and germ, which contain nutrients and _fiber. Examples of refi_ned carbohydrates include white bread and white rice.
  
• Certain intestinal diseases. Diseases that affect normal absorption of nutrients, such as Crohn’s disease, are associated with gallstones.
  
• Metabolic syndrome, diabetes, and insulin resistance. These conditions increase the risk of gallstones. Metabolic syndrome also increases the risk of gallstone complications. Metabolic syndrome is a group of traits and medical conditions linked to being overweight or obese that puts people at risk for heart disease and type 2 diabetes.
  

More information about these conditions is provided in the NIDDK health topic, Insulin Resistance and Prediabetes.

Pigment stones tend to develop in people who may have the following:

• cirrhosis—a condition in which the liver slowly deteriorates and malfunctions due to chronic, or long lasting, injury
  
• infections in the bile ducts
  
• severe hemolytic anemias—conditions in which red blood cells are continuously broken down, such as sickle cell anemia
  

The biliary tract consists of the gallbladder and the bile ducts. The bile ducts carry bile and other digestive enzymes from the liver and pancreas to the duodenum—the first part of the small intestine.

The liver produces bile—a fluid that carries toxins and waste products out of the body and helps the body digest fats and the fat-soluble vitamins A, D, E, and K. Bile mostly consists of cholesterol, bile salts, and bilirubin. Bilirubin, a reddish-yellow substance, forms when hemoglobin from red blood cells breaks down. Most bilirubin is excreted through bile.

Many people with gallstones do not have symptoms. Gallstones that do not cause symptoms are called asymptomatic, or silent, gallstones. Silent gallstones do not interfere with the function of the gallbladder, liver, or pancreas.

If gallstones block the bile ducts, pressure increases in the gallbladder, causing a gallbladder attack. The pain usually lasts from 1 to several hours.1 Gallbladder attacks often follow heavy meals, and they usually occur in the evening or during the night.

Gallbladder attacks usually stop when gallstones move and no longer block the bile ducts. However, if any of the bile ducts remain blocked for more than a few hours, complications can occur. Complications include inflammation, or swelling, of the gallbladder and severe damage or infection of the gallbladder, bile ducts, or liver.

A gallstone that becomes lodged in the common bile duct near the duodenum and blocks the pancreatic duct can cause gallstone pancreatitis—inflammation of the pancreas. Left untreated, blockages of the bile ducts or pancreatic duct can be fatal.

A health care provider will usually order an ultrasound exam to diagnose gallstones. Other imaging tests may also be used.

• Ultrasound exam. Ultrasound uses a device, called a transducer, which bounces safe, painless sound waves off organs to create an image of their structure. A specially trained technician performs the procedure in a health care provider’s office, outpatient center, or hospital, and a radiologist—a doctor who specializes in medical imaging—interprets the images. Anesthesia is not needed. If gallstones are present, they will be visible in the image. Ultrasound is the most accurate method to detect gallstones.
  
• Computerized tomography (CT) scan. A CT scan is an x ray that produces pictures of the body. A CT scan may include the injection of a special dye, called contrast medium. CT scans use a combination of x rays and computer technology to create three-dimensional (3-D) images. CT scans require the person to lie on a table that slides into a tunnel-shaped device where the x rays are taken. An x-ray technician performs the procedure in an outpatient center or hospital, and a radiologist interprets the images. Anesthesia is not needed. CT scans can show gallstones or complications, such as infection and blockage of the gallbladder or bile ducts. However, CT scans can miss gallstones that are present.
  

• Magnetic resonance imaging (MRI). MRI machines use radio waves and magnets to produce detailed pictures of the body’s internal organs and soft tissues without using x rays. A specially trained technician performs the procedure in an outpatient center or hospital, and a radiologist interprets the images. Anesthesia is not needed, though people with a fear of confi_ned spaces may receive light sedation. An MRI may include the injection of contrast medium. With most MRI machines, the person lies on a table that slides into a tunnel-shaped device that may be open ended or closed at one end; some newer machines allow the person to lie in a more open space. MRIs can show gallstones in the ducts of the biliary system.
  

• Cholescintigraphy. Cholescintigraphy—also called a hydroxyl iminodiacetic acid scan, HIDA scan, or hepatobiliary scan—uses an unharmful radioactive material to produce pictures of the biliary system. In cholescintigraphy, the person lies on an exam table and a health care provider injects a small amount of unharmful radioactive material into a vein in the person’s arm. The health care provider may also inject a substance that causes the gallbladder to contract. A special camera takes pictures of the radioactive material as it moves through the biliary system. A specially trained technician performs the procedure in an outpatient center or hospital, and a radiologist interprets the images. Anesthesia is not needed. Cholescintigraphy is used to diagnose abnormal contractions of the gallbladder or obstruction of the bile ducts.
  

• Endoscopic retrograde cholangiopancreatography (ERCP). ERCP uses an x ray to look into the bile and pancreatic ducts. After lightly sedating the person, the health care provider inserts an endoscope—a small, _flexible tube with a light and a camera on the end—through the mouth into the duodenum and bile ducts. The endoscope is connected to a computer and video monitor. The health care provider injects contrast medium through the tube into the bile ducts, which makes the ducts show up on the monitor. The health care provider performs the procedure in an outpatient center or hospital. ERCP helps the health care provider locate the affected bile duct and the gallstone. The stone is captured in a tiny basket attached to the endoscope and removed. This test is more invasive than other tests and is used selectively.
  

Health care providers also use blood tests to look for signs of infection or inflammation of the bile ducts, gallbladder, pancreas, or liver. A blood test involves drawing blood at a health care provider’s office or commercial facility and sending the sample to a lab for analysis.

Gallstone symptoms may be similar to those of other conditions, such as appendicitis, ulcers, pancreatitis, and gastro esophageal reflux disease.

Sometimes, silent gallstones are found when a person does not have any symptoms. For example, a health care provider may notice gallstones when performing ultrasound for a different reason.

If gallstones are not causing symptoms, treatment is usually not needed. However, if a person has a gallbladder attack or other symptoms, a health care provider will usually recommend treatment. A person may be referred to a gastroenterologist—a doctor who specializes in digestive diseases—for treatment. If a person has had one gallbladder attack, more episodes will likely follow.

The usual treatment for gallstones is surgery to remove the gallbladder. If a person cannot undergo surgery, nonsurgical treatments may be used to dissolve cholesterol gallstones.

Surgery to remove the gallbladder, called cholecystectomy, is one of the most common operations performed on adults in the United States.
The gallbladder is not an essential organ, which means a person can live normally without a gallbladder. Once the gallbladder is removed, bile _flows out of the liver through the hepatic and common bile ducts and directly into the duodenum, instead of being stored in the gallbladder.

Surgeons perform two types of cholecystectomy: Laparoscopic and Open Cholecystectomy.

Laparoscopic cholecystectomy

In a laparoscopic cholecystectomy, the surgeon makes several tiny incisions in the abdomen and inserts a laparoscope—a thin tube with a tiny video camera attached. The camera sends a magni_fied image from inside the body to a video monitor, giving the surgeon a close-up view of organs and tissues. While watching the monitor, the surgeon uses instruments to carefully separate the gallbladder from the liver, bile ducts, and other structures. Then the surgeon removes the gallbladder through one of the small incisions. Patients usually receive general anesthesia.
Most cholecystectomies are performed with laparoscopy. Many laparoscopic cholecystectomies are performed on an outpatient basis, meaning the person is able to go home the same day. Normal physical activity can usually be resumed in about a week.

Open cholecystectomy

An open cholecystectomy is performed when the gallbladder is severely infl_amed, infected, or scarred from other operations. In most of these cases, open cholecystectomy is planned from the start. However, a surgeon may perform an open cholecystectomy when problems occur during a laparoscopic cholecystectomy. In these cases, the surgeon must switch to open cholecystectomy as a safety measure for the patient.
To perform an open cholecystectomy, the surgeon creates an incision about 4 to 6 inches long in the abdomen to remove the gallbladder.4 Patients usually receive general anesthesia. Recovery from open cholecystectomy may require some people to stay in the hospital for up to a week. Normal physical activity can usually be resumed after about a month.

A small number of people have softer and more frequent stools after gallbladder removal because bile flows into the duodenum more often. Changes in bowel habits are usually temporary; however, they should be discussed with a health care provider. Though complications from gallbladder surgery are rare, the most common complication is injury to the bile ducts. An injured common bile duct can leak bile and cause a painful and possibly dangerous infection. One or more additional operations may be needed to repair the bile ducts. Bile duct injuries occur in less than 1 percent of cholecystectomies.

An intraoperative cholangiogram is imaging of the bile ducts during a surgical procedure. This helps the surgeon get oriented in the body and can reduce the risk of injury to the bile ducts. Studies on the use of intraoperative cholangiography suggest it can be a cost-effective measure for protecting patient safety.

Most surgeons request an intraoperative cholangiogram in any procedure when they will be working with or around the bile ducts, particularly in a cholecystectomy, where the practitioner removes the gallbladder. These procedures are often performed endoscopically, with the use of tools inserted through small incisions and guided by a camera. It can be easy to get disoriented inside the body during such surgeries, and a surgeon may confuse structures near the gallbladder or accidentally injure the bile ductwith pressure or clipping.

In the intraoperative cholangiogram, a technician injects a contrast medium that will highlight the bile ducts on an x-ray. Once the medium has a chance to circulate, a series of images can be taken to watch it move through the bile ducts. The resulting images highlight the anatomical structures in the area and provide important information for the surgeon about the location of the common bile duct. If there is a problem as a result of surgery, the surgeon can look for indications of potential trouble, which might include leaking contrast medium or an area of obstruction.

When a surgeon recommends a gallbladder removal or other surgery in this area, this may include a request for an intraoperative cholangiogram. Information about the test can be provided to the patient along with other material about the surgery. Surgeons typically strongly recommend imaging because it makes the surgery safer for the patient. General surgeons and others who perform gallbladder removal also have concerns about malpractice accusations, and thus take reasonable precautions to reduce the risk of complications and identify surgical errors as quickly as possible.

This test does carry some risks, as some patients are allergic to contrast media. People should discuss their allergies before the surgery so the doctor can determine if the intraoperative cholangiogram is likely to be safe. The risks of not checking on the bile ducts during surgery could be the primary concern. Patients who do not receive such imaging might need to go under anesthesia again for a corrective surgery to address an issue caused during the initial procedure, and this can increase the chance of infection and other complications.

• Gallstones are hard particles that develop in the gallbladder.
  
• Imbalances in the substances that make up bile cause gallstones. Gallstones may form if bile contains too much cholesterol, too much bilirubin, or not enough bile salts. Scientists do not fully understand why these imbalances occur.
  
• Women, people over age 40, people with a family history of gallstones, American Indians, and Mexican Americans have a higher risk of developing gallstones.
  
• Many people with gallstones do not have symptoms. Gallstones that do not cause symptoms are called asymptomatic, or silent, gallstones.
  
• If gallstones block the bile ducts, pressure increases in the gallbladder, causing a gallbladder attack.
  
• Gallbladder attacks often follow heavy meals, and they usually occur in the evening or during the night.
  
• Gallstone symptoms may be similar to those of other conditions.
  
• If gallstones are not causing symptoms, treatment is usually not needed. However, if a person has a gallbladder attack or other symptoms, a health care provider will usually recommend treatment.
  
• The usual treatment for gallstones is surgery to remove the gallbladder. If a person cannot undergo surgery, nonsurgical treatments may be used to dissolve cholesterol gallstones. A health care provider may use endoscopic retrograde cholangiopancreatography (ERCP) to remove stones in people who cannot undergo surgery or to remove stones from the common bile duct in people who are about to have gallbladder removal surgery.
  
• The gallbladder is not an essential organ, which means a person can live normally without a gallbladder. Once the gallbladder is removed, bile _flows out of the liver through the hepatic and common bile ducts and directly into the duodenum, instead of being stored in the gallbladder.