Introduction

Many people have gallstones without noticing them. If gallstones don't cause any problems, there's usually no need to treat them. But if symptoms such as cramp-like abdominal pain do develop, the question is: Is it enough to only treat the symptoms, or is surgery needed?

Gallbladder surgery is one of the most common operations in Germany. Each year in Germany, about 175,000 women and men have their gallbladder removed, mostly because they have gallstones that are causing symptoms or complications.

Gallstones can form in the gallbladder itself, and, less frequently, in the bile ducts. Most bile duct stones first form in the gallbladder and then migrate into the common bile duct.

At a glance

• Gallstones often go unnoticed.
• But they sometimes lead to a cramping pain (colic) in the upper abdomen.
• Colic increases the risk of complications like an inflammation of the gallbladder.
• Surgery to remove the gallbladder is only needed if the symptoms keep coming back or there is a high risk of complications.

Symptoms

A lot of people who have gallstones don't know about them because they don't have any symptoms, or only very general symptoms. Whether someone has symptoms and what kind of symptoms they have will depend on where the gallstones are, how big they are, and whether they are causing any complications.

Gallstones may be located in the gallbladder or in the bile ducts. The most typical sign of gallstones is very unpleasant, cramping pain in the upper abdomen (colic). Colic can develop if the gallstones are blocking the exit of the gallbladder or the opening of the bile duct (where it joins the duodenum). The pain comes in waves. It usually gets a bit better within an hour, eventually disappearing completely a few hours later. Sometimes it radiates into your right shoulder and your back. Experts also use the term cholelithiasis.

People with gallstones also report other symptoms such as bloating, unclear abdominal pain, frequent flatulence, diarrhea, heartburn, nausea, and vomiting.

Research has shown

• that about 2 to 4 out of 100 people with gallstones have noticeable symptoms within one year, and
• about 50 out of 100 people who have already had symptoms like colic will get them again within two years.

Gallstones in the bile ducts can also lead to jaundice (sometimes called icterus), a condition where the skin and the eyes take on a yellowish color. Here the jaundice is caused by bile duct stones preventing proper bile drainage. The bile pigment (bilirubin) produced in the liver can then no longer drain off with the bile. More of this yellow bilirubin flows into the blood and causes the discoloration. This may also make urine (pee) darker, and stool (poop) may have a lighter color.

Gallstones in the gallbladder and common bile duct

Causes

The gallbladder is a small, pear-shaped organ located on the right side of the abdomen, just below the liver. It stores and concentrates bile from the liver.

The body needs bile to digest fats in the bowel. It is made up of water and several other substances, some of which do not dissolve in water. Gallstones form if these substances clump together. Most gallstones are made mainly of cholesterol. Other, less common, types of gallstones are known as pigment stones. They consist of calcium and bilirubin, a yellowish pigment that is made when the hemoglobin in red blood cells is broken down.

Risk factors

Gallstones become more common over the age of 40. If several of your relatives have had gallstones, it's more likely that you will get them as well.

The following factors also increase the risk of gallstones:

• Pregnancy
• Using the contraceptive pill or estrogen tablets, such as during menopause (hormone therapy).
• Gallbladder dysfunction where the organ can no longer contract properly, making gallstones more likely
• Short bowel syndrome due to the surgical removal of a large part of the small intestine.
• Diabetes
• Taking certain antidiabetic medications (GLP-1 analogs)
• Cirrhosis of the liver, for example due to excessive alcohol consumption
• Being very overweight
• Severe weight loss in a short time, such as following gastric bypass
• Special high-calorie tube feed nutrition.
• Hemolysis, a disease that causes increased breakdown of red blood cells

Prevalence

It is estimated that between 5 and 25% of the population have gallstones. People aged over 40 are affected more often, and women more than men. But most people don’t have any symptoms.

Effects

About half of those affected with symptoms only have colic once or only have short-term symptoms caused by gallstones. Small stones sometimes pass by themselves.

But gallstones can also cause complications such as inflammation of the gallbladder or the pancreas. The risk of complications from gallstones is increased if typical symptoms such as colic have already developed: Each year, about 0.2% of people with gallstones and no symptoms experience complications; about 2% of people with gallstone symptoms develop complications.

Diagnosis

Gallstones are sometimes found by chance, for example during an ultrasound scan of the abdomen. But the doctor will often specifically look for them because you have symptoms that could be signs of gallstones. Before any diagnostic tests are done, it is important to describe your symptoms to the doctor in detail.

Diagnosing gallstones is normally not very complicated. After you have talked to the doctor, you will have a physical examination and an ultrasound scan of your abdomen. This will usually be enough to make a diagnosis. More tests may be necessary to make sure the symptoms aren't being caused by other medical problems.

Diagnosing gallstones located in the bile duct may be more complicated. If there is reason to believe you might have bile duct stones, an ultrasound scan will usually be done there, too. But because they are more difficult to spot on a normal ultrasound image, that might be followed up by an endoscopic ultrasound examination (endosonography). In this examination, an endoscope with an ultrasound probe is pushed through your food pipe, your stomach, and the first part of the duodenum, to the opening of the bile duct. Bile duct stones can then usually be seen well. You will be given a sedative (short anesthetic) before the examination.

In more rare cases, a diagnostic procedure called endoscopic retrograde cholangiopancreatography (ERCP) is performed. It is usually only used if doctors are very sure that there are stones in the bile duct. This also involves inserting an endoscope through the mouth and gently pushing it along the food pipe, stomach and into the duodenum, where the bile duct opening is found. The doctor will then inject a contrast agent into the duct so that any stones become visible on the x-ray image. With the help of the endoscope, the stones can then not only be detected but also removed during the examination.

Magnetic resonance cholangiopancreatography (MRCP) is another alternative. You then lie in a magnetic resonance scanner that generates layered images of the bile duct system from outside the body. A separate procedure is then needed if gallstones are found that have to be removed.

Prevention

There is no reliable research into whether certain behaviors can help to prevent gallstones. But there are some suggestions that a healthy lifestyle can help to reduce the risk of gallstones and the connected symptoms. That includes taking regular exercise, having a balanced diet, and avoiding being very overweight.

Treatment

If gallstones don't cause any problems, there's usually no need to treat them. A lot of people with gallstones don't have any symptoms for a long time. What's more, any treatment can have side effects, and surgery always carries certain risks.

Box

Doctors who recommend gallbladder surgery have to inform you of your right to get a second medical opinion free of charge. Our decision aid on gallbladder surgery can also help you to consider the pros and cons of this kind of procedure.

People who have very large gallstones or specific types of porcelain gallbladder (calcification of the gallbladder wall) are at greater risk of developing gallbladder cancer. Surgical removal of the gallbladder may then be considered even if they don't have any symptoms.

Several painkillers and antispasmodic medications are available for the relief of painful colic. Symptoms like bloating or nausea can also be treated with medicine.

There are medications that can dissolve gallstones, but they are only rarely used because they have a very limited effect and only help with small cholesterol stones.

Removing the gallbladder or stones from the bile duct is the only way to permanently prevent painful colic and complications. Whether and when this step is taken will depend on several factors, including the severity of symptoms, the risk of complications, and any other medical conditions.

Further information

When people are ill or need medical advice, they usually go to see their family doctor first. You can read about how to find the right doctor in our topic "Health care in Germany" – and our list of questions can help you to prepare for your appointment.

Sources

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• Brazzelli M, Cruickshank M, Kilonzo M et al. Clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones or cholecystitis: a systematic review and economic evaluation. Health Technol Assess 2014; 18(55): 1-101, v-vi. [PMC free article: PMC4781329] [PubMed: 25164349]
• Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselerkrankungen (DGVS), Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). Prävention, Diagnostik und Therapie von Gallensteinen (S3-Leitlinie, in Überarbeitung). AWMF-Registernr.: 021-008. 2017.
• European Association for the Study of the Liver (EASL). EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol 2016; 65(1): 146-181. [PubMed: 36464532]
• Fraquelli M, Casazza G, Conte D et al. Non-steroid anti-inflammatory drugs for biliary colic. Cochrane Database Syst Rev 2016; (9): CD006390. [PMC free article: PMC6457716] [PubMed: 27610712]
• Gurusamy KS, Davidson BR. Gallstones. BMJ 2014; 348: g2669. [PubMed: 24755732]
• Gutt C, Schläfer S, Lammert F. The Treatment of Gallstone Disease. Dtsch Arztebl Int 2020; 117(9): 148-158. [PMC free article: PMC7132079] [PubMed: 32234195]
• Institut für Qualitätssicherung und Transparenz im Gesundheitswesen (IQTIG). Bundesauswertung Cholezystektomie (Erfassungsjahr 2021).

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