Gallstones

The majority of gallstones do not cause any symptoms, and do not need treatment.

Pain at the top, right side of the abdomen can occur if the gallstone blocks the cystic duct (which links the gall bladder to the common bile duct) during contraction of the gallbladder. This is known as biliary colic. The pain is often linked to fatty meals (when the gall bladder contracts). Typically the pain is intense for at least 30 minutes but begins to subside after an hour, as the gall bladder begins to relax. It is unusual for an attack of biliary colic to last longer than 6 hrs.

In some cases of gallstone disease the stone permanently blocks the cystic duct, resulting in inflammation of the gallbladder. This condition is known as acute cholecystitis. In acute cholecystitis the pain is severe, unrelenting and prolonged (usually longer than 5 hours). The pain is typically accompanied by a fever. Bacterial infection can also occur requiring the affected patient to stay in hospital to receive antibiotics.

Occasionally the gallstone may move out of the gall bladder and into the tube which carries bile to the intestine (known as the common bile duct). This blocks the flow of bile into the intestine and can cause jaundice (yellow skin and eyes). The patient may also notice dark urine and light coloured faeces.

Acute cholangitis (inflammation of the common bile duct) occurs if bacteria enter the blocked tube. This leads to a high fever often with pain, vomiting, and extreme tiredness.

Gallstones can become lodged at the junction of the pancreas and common bile duct. This leads to inflammation of the pancreas (pancreatitis).

Blood tests are typically normal in biliary colic when it is not complicated by inflammation or infection of the gallbladder.

Blood tests can show signs of inflammation and infection:

• FBC – raised white cells indicate infection
• CRP – an elevated result indicates inflammation
• ESR – an elevated result indicates inflammation

Blood tests can also demonstrate any damage to the liver or pancreas as a result of blockage or infection:

• Liver function tests – One of these tests called alkaline phosphatase (ALP) is very high in infection of the bile ducts.  Another test is bilirubin which will be raised if the bile ducts are blocked
• Amylase – Typically raised if the pancreas is damaged

An ultrasound scan will show almost all gallstones over 4mm.  CT and MRI scans may also be used.

Treatment for gallstones which cause pain is via removal of the gall bladder (cholecystectomy).  This is usually done by key-hole surgery and normally involves only an overnight stay in hospital.  The operation is undertaken some weeks after an attack to let the gall bladder settle down before surgery.

Alternatives to surgery can only be used in a few patients.  These include shattering the stones with shockwaves, injecting a solution to dissolve the stones or medication.  If the gall bladder is not removed through surgery then long-term treatment is required to prevent new stones.

If gallstones are picked up by chance, but have caused no pain, then no treatment is required.

Gallstones in the common bile duct need to be removed urgently. This can be done by ERCP (endoscopic retrograde cholangiopancreatography) which is technique related to endoscopy. In ERCP a thin long flexible tube (endoscope) is used to reach the common bile duct and dye is injected to outline the stone. The stone can then be visualised on an X ray image. Once the location of the stone is known, it can then be removed as part of the ERCP procedure.

In most patients with gallstones in the common bile duct the gall bladder will also be removed to prevent future stones. 

What happens when I don’t have a gall bladder?
Hardly anyone misses their gall bladder.  Bile will drain continuously into the intestines but usually doesn’t cause any problems.  Only about 1 in 100 people will have diarrhoea which can be easily treated.