Gallstones (Cholelithiasis)

What are Gallstones?

Gallstones are hard deposits that form in the gallbladder, a small organ that stores bile produced by the liver. Ultrasound is the best first-line imaging test for detecting gallstones.

Imaging Appearance

On ultrasound, gallstones show characteristic features:

• Bright (echogenic) structures inside the gallbladder
• Posterior acoustic shadowing - dark shadow behind the stone
• Mobility - stones move with position changes (unlike polyps)
• Can be single or multiple
• Size ranges from tiny gravel to several centimeters

The combination of echogenicity and shadowing makes ultrasound diagnosis highly accurate (95% sensitivity).

Types of Gallstones

1. Cholesterol Stones (80%)

• Yellow-green color
• Made of hardened cholesterol
• Associated with obesity, rapid weight loss
• More common in women

2. Pigment Stones (20%)

• Dark brown or black
• Made of bilirubin
• Associated with hemolytic anemia, cirrhosis, infections

3. Mixed Stones

• Combination of cholesterol and pigment
• Most common type overall

Risk Factors

The "4 F's" (Classic Risk Factors):

• Female (2-3x higher risk)
• Forty (age ＞ 40)
• Fertile (pregnancy increases risk)
• Fat (obesity)

Other Risk Factors:

• Rapid weight loss or bariatric surgery
• High-fat, low-fiber diet
• Diabetes
• Family history
• Certain medications (estrogen, fibrates)
• Crohn's disease
• Native American or Hispanic ethnicity

Symptoms

Asymptomatic (70-80%)

Most people with gallstones have no symptoms and are diagnosed incidentally on imaging.

Symptomatic - Biliary Colic (20-30%)

Classic Presentation:

• Severe pain in right upper abdomen
• Radiates to back or right shoulder blade
• Triggered by fatty meals
• Lasts 30 minutes to several hours
• Nausea and vomiting
• Pain typically subsides completely between attacks

Complications (Require Treatment)

1. Acute Cholecystitis (Gallbladder Inflammation):

• Persistent severe pain ＞ 6 hours
• Fever and chills
• Positive Murphy's sign (pain on palpation)
• Requires antibiotics or surgery

2. Choledocholithiasis (Stone in Bile Duct):

• Jaundice (yellow skin/eyes)
• Dark urine, pale stools
• Elevated bilirubin and liver enzymes
• May require ERCP to remove stone

3. Gallstone Pancreatitis:

• Severe upper abdominal pain
• Nausea, vomiting
• Elevated lipase/amylase
• Can be life-threatening

4. Cholangitis (Bile Duct Infection):

• Fever, jaundice, abdominal pain (Charcot's triad)
• Medical emergency requiring antibiotics and drainage

Diagnosis

Ultrasound (First-Line Test)

• 95% sensitive for gallstones
• Safe, quick, no radiation
• Can assess gallbladder wall thickness (cholecystitis)
• May miss small stones or stones in bile duct

Other Tests:

• CT scan - Less sensitive but can detect complications
• MRCP - Best for visualizing bile ducts
• HIDA scan - Assesses gallbladder function
• Endoscopic ultrasound (EUS) - For small duct stones

Blood Tests:

• Liver function tests (ALT, AST, ALP, bilirubin)
• Lipase (if pancreatitis suspected)
• CBC (white blood cell count)

Treatment

Asymptomatic Gallstones

Watchful Waiting (Standard Approach):

• No treatment needed
• Only 20% will develop symptoms over 20 years
• Surgery not recommended unless symptoms develop

Exceptions (Consider Surgery):

• Very large stones (＞ 3 cm) - higher cancer risk
• Porcelain gallbladder (calcified wall)
• Gallbladder polyps ＞ 1 cm
• Diabetic patients (higher complication risk)

Symptomatic Gallstones

Surgical Treatment (Gold Standard):

Laparoscopic Cholecystectomy:

• Minimally invasive surgery to remove gallbladder
• 3-4 small incisions
• Same-day or overnight stay
• Recovery in 1-2 weeks
• Cure rate: 95%+

Timing:

• Elective surgery for recurrent biliary colic
• Urgent surgery for acute cholecystitis

Non-Surgical Options (Limited Use)

Oral Dissolution Therapy:

• Ursodeoxycholic acid (UDCA)
• Only for small cholesterol stones
• Takes months to years
• High recurrence rate (50%)
• Rarely used

Shock Wave Lithotripsy:

• Breaks stones with sound waves
• Limited effectiveness
• High recurrence
• Not commonly performed

Living Without a Gallbladder

After cholecystectomy:

• No major lifestyle changes needed
• Bile flows continuously from liver to intestine
• Most people have normal digestion
• Some may experience temporary loose stools
• Can eat normally (low-fat diet initially)

Prevention

Dietary Modifications:

• Maintain healthy weight
• Avoid rapid weight loss (＜ 1.5 lbs/week)
• Eat regular meals (don't skip breakfast)
• Include healthy fats (olive oil, nuts)
• High-fiber diet
• Stay hydrated

Lifestyle:

• Regular physical activity
• Avoid crash diets
• Control diabetes
• Limit saturated fats

Prognosis

Asymptomatic Gallstones:

• 80% remain asymptomatic lifelong
• 1-2% per year develop symptoms

After Surgery:

• Excellent outcomes
• 95% symptom resolution
• ＜ 1% complication rate
• Can return to normal activities quickly

What Should You Do?

If gallstones are found on ultrasound:

No Symptoms:

1. No treatment needed
2. Be aware of symptoms of biliary colic
3. No dietary restrictions necessary
4. Regular follow-up not required

With Symptoms:

1. Consult a surgeon about cholecystectomy
2. Consider timing of surgery
3. Manage pain during attacks (anti-inflammatories)
4. Avoid fatty meal triggers

Related Imaging Terms

• Cholecystitis - Inflamed gallbladder
• Biliary sludge - Thick bile (precursor to stones)
• Gallbladder polyp - Growth on gallbladder wall

Common Questions

Can diet dissolve gallstones?

No. Once formed, gallstones cannot be dissolved by diet alone. Medications may work for specific stone types but are rarely used.

Will I need to change my diet after surgery?

Most people can eat normally after recovery. Some may need to limit fatty foods temporarily.

Can gallstones come back after surgery?

No. Once the gallbladder is removed, you cannot form new gallstones. However, stones can rarely form in bile ducts.

Is surgery always necessary?

No. If you have no symptoms, surgery is typically not recommended. Only symptomatic stones require treatment.

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Medical Disclaimer: This information is educational. Discuss treatment options with your surgeon or gastroenterologist based on your specific situation.