All You Ever Wanted to Know about Gallstones

What Is The Gallbladder?

Your gall bladder is an organ that sits under your liver on the upper right part of your abdomen. It stores and concentrates bile from the liver. While the gallbladder contains bile, it does not actually make bile – that is done by the liver.

Bile is necessary for the absorption of fat in our diet – rather like soap, it allows fat to mix with water making it easier to absorb from the small bowel.

Whenever we eat a meal rich in fat, our gallbladders contract, squirting out a small amount of bile into the small bowel to aid digestion.

Location of gallbladder (liver partly cut away)
How Then Do Gallstones Form?

Gallstones form when the bile has become too concentrated.

It is like thick soya sauce which has been kept in the fridge for too long – it solidifies and forms crystals.

Initially, the gallstones are small, like sand, but over time they can grow quite big. The largest stone I have removed via surgery was about 5cm long.

How Do I Know If I Have Gallstones?

Here are some common symptoms if you have gallstones. Symptoms can also vary, depending on where the stone is.

  • Jaundice (where your skin and eyes turn yellow)
  • Nausea & vomiting
  • Upper abdominal discomfort when you eat fatty food (fat intolerance)
  • Flatulance (wind, belching)
  • Upper abdominal pain (centre and right upper abdomen)
  • Fever

On a positive point, although gallstones are common, not all cause trouble.

Typically you will have pain because the gallstone gets stuck at the narrow part or neck of the gallbladder. Whenever you eat a fatty or rich meal, the gall bladder contracts but the opening is blocked. It’s like pushing against a closed door.

When this happens, you feel pain. This pain is usually felt in the upper part of the abdomen in the centre or to the right under the ribcage.

If your gallstone gets well and truly stuck at the neck of the gallbladder, the gallbladder becomes inflamed, red and swollen.  It may become infected so you may have a high fever along with the pain. You may feel a tender mass in your upper abdomen. This is known as cholecystitis.

Cholecystitis means an inflamed gallbladder
CT scan showing an inflammed gallbladder

If you don’t get it treated, your gallbladder can become gangrenous and even perforate. Sometimes, if the gallstone is large and erodes its way into your small bowel, the gallstone can block the small bowel. This is known as “gallstone ileus”.

If your gallstones are small, they may pass into the common bile duct. There, they may obstruct the common bile duct and block the flow of bile from the liver into the small bowel. This causes jaundice where your skin and eyes turn yellow and your stools may become pale and float.  Jaundice is always potentially serious and if you have jaundice, you should see a doctor immediately.

If the obstructed bile becomes infected, you will develop a high fever with the jaundice. This could lead to septicaemia (infection in the bloodstream) which is a serious and dangerous condition.

If the stone gets stuck at the lower end of the common bile duct close to the pancreatic duct, the surrounding inflammation could block the pancreatic duct as well leading to a condition called acute pancreatitis. Acute pancreatitis is a serious disease that can result in multi organ failure and death.

Will Large Gallstones Cause More Problems Than Small Gallstones?

Size is NOT the cause of the severity of pain from having gallstones. Large stones tend to cause inflammation and block the gall bladder. Small stones slip out but are more likely to get stuck at the common bile duct causing jaundice.

Pain caused by gallstones can be severe – some patients report that it is the worst pain they have ever had.

I Suspect I Might Have Gallstones. What Do I Do?

If you think you may have gallstones, contact me and I can arrange for you to take some tests such as an ultrasound scan of the abdomen and some blood tests. You may also have your abdomen scanned.

Ultrasound scan showing multiple gallstones
I Have Gallstones. What Should I Do Now?

If your gallstones are causing symptoms, I recommend that you remove them, together with the gallbladder. This can be done with keyhole surgery and it is specifically called laparoscopic cholecystectomy.

91% of all my patients’ gallbladder operations are done this way.

You’ll be assessed (with additional tests or procedures) before we progress to surgery. If your gallstones have already caused acute pancreatitis, we may want to let the inflammation in the pancreas settle down before surgery.

Why Can’t We Remove Just The Gallstones?
Why Must We Remove The Gallbladder Too?

The stones are inanimate and sit in the gallbladder or bile ducts. They do not become painful by themselves (because they have no nerve supply) but they cause the gallbladder to become painful. Removing just the stones therefore may not get rid of the problem. Besides, the gallbladder is the stone factory – picking out the stones and leaving the factory behind is inviting further trouble in future when more stones form!

Sometimes there are hundreds of tiny gallstones like sand. It is impossible to pick these up one by one. If stones spill out and fall between the loops of your small bowel, it becomes difficult to find and remove all the stones.

Gallbladder full of stones

Based on these reasons, if you have gallstones, the recommended (as well as recognised and accepted) treatment is to remove the entire gallbladder with the stones inside using a method we call laparoscopic cholecystectomy.

Will I Still Be Able To Live Healthy Life Without A Gallbladder?

After we remove the gallbladder, you will still be able to eat and digest food normally, including fatty food (though of course too much fat is also not good for the heart amongst other things!). You do not need to restrict your diet or activity.

The gallbladder does not produce bile – that is produced by the liver. It merely stores and concentrates the bile. Like the appendix, it is present in your body but it is not 100% needed.

Some patients may notice their stools become softer after their gallbladder operation. In general, if done properly, you will have very few problems after gallbladder removal.

Can We Dissolve Gallstones With Medication?

This won’t work on all types of gallstones. Medication works best if you have small cholesterol stones under 1cm in size. These stones are not visible on X Rays or CT scans and are best seen on ultrasound scan. You will need to take medication for 6 – 18 months for it to work. During this time, you may still get symptoms and complications due to your gallstones. After stopping treatment, over 50% of patients develop more stones in the following years. As the success rate is less than 50% it is hardly ever used now to treat gallstones.

I have gallstones but I have no pain. Do I really need surgery?

If you have gallstones but you have no symptoms (see above), most guidelines recommend leaving the stones alone.
However there is a 25% chance you may get symptoms due to your gallstones in the future.
There are certain situations when we might still recommend removing the gall bladder (and stones) even though you are well.

  • large stones over 2cm. This is because there is a higher risk of malignancy with larger stones.
  • porcelain gallbladder. A porcelain gallbladder is when the gall bladder wall has become hardened with calcium. The risk of gall bladder cancer is high (25%) so surgical removal is strongly recommended.
  • if you have gallstones and are going to be in a situation where surgical help is not easily available (example: going on a long ocean cruise or an Antarctic expedition or living in a remote place far from hospitals). If the gallstones decide to play up in the middle of the ocean you are on your own!
  • patients with sickle cell anaemia should have their gallstones removed because it can be difficult to tell the difference between severe pain due to gallstones and pain due to a sickle cell crisis.
  • patients with spinal cord problems causing numbness or loss of sensation over the abdomen. In this situation, the patient may not be aware if the gall bladder becomes inflammed and delayed diagnosis could lead to one of the complications listed above.
A large gallstone