Gallstones: Pain, Symptoms, Causes, Treatment, Types & Surgery Options

A man experiences pain from biliary colic. The most common symptom of gallstones is biliary colic.Source: iStock

What are the signs and symptoms of gallstones? Do they cause pain?

The majority of people with gallstones have no signs or symptoms and are unaware of their gallstones. (The gallstones are "silent.") These gallstones often are found as a result of tests (for example, ultrasound, or X-rays of the abdomen) performed while evaluating medical conditions other than gallstones. Symptoms can appear later in life, however, after many years without symptoms. Thus, over a period of five years, approximately 10% of people with silent gallstones will develop symptoms. Once symptoms develop, they are likely to continue and often will worsen.

When signs and symptoms of gallstones occur, they virtually always occur because the gallstones obstruct the bile ducts.

The most common symptom of gallstones is biliary colic. Biliary colic is a very specific type of pain, occurring as the primary or only symptom in 80% of people with gallstones who develop symptoms. Biliary colic occurs when the bile ducts (cystic, hepatic ducts, or common bile ducts) are suddenly blocked by a gallstone. Slowly progressing obstruction, as from a tumor, does not cause biliary colic. Behind the obstruction, fluid accumulates and distends the ducts and gallbladder. In the case of hepatic duct or common bile duct obstruction, this is due to continued secretion of bile by the liver. In the case of cystic duct obstruction, the wall of the gallbladder secretes fluid into the gallbladder. The distention of the ducts or gallbladder causes biliary colic.

Characteristically, biliary colic comes on suddenly or builds rapidly to a peak over a few minutes.

It is a constant pain; it does not come and go, though it may vary in intensity while it is present. IT is not cramp-like.
It lasts for 15 minutes to 4-5 hours. If the pain lasts more than 4-5 hours, it means that a complication – usually cholecystitis – has developed.
The pain usually is severe, but the movement does not make the pain worse. In fact, patients experiencing biliary colic often walkabout or writhe (twist the body in different positions) in bed trying to find a comfortable position.
Biliary colic often is accompanied by nausea.
Most commonly, biliary colic is felt in the middle of the upper abdomen just below the sternum.
The second most common location for pain is the right upper abdomen just below the margin of the ribs.
Occasionally, the pain also may be felt in the back at the lower tip of the scapula on the right side.
On rare occasions, the pain may be felt beneath the sternum and is mistaken for angina or a heart attack.
An episode of biliary colic subsides gradually once the gallstone shifts within the duct so that it is no longer causing an obstruction.

Biliary colic is a recurring symptom. Once the first episode occurs, there are likely to be other episodes. Moreover, there is a pattern of recurrence for each individual, that is, in some individuals, the episodes tend to remain frequent while in others they are infrequent. The majority of people who develop biliary colic do not go on to develop cholecystitis or other complications. There is a misconception that contraction of the gallbladder is what causes the obstruction of the ducts and biliary colic. Eating, even fatty foods, does not cause biliary colic; most episodes of biliary colic occur during the night, long after the gallbladder has emptied.

Gallstones are blamed for many symptoms they do not cause. Among the symptoms gallstones do not cause are:

dyspepsia (including abdominal bloating and discomfort after eating),
intolerance to fatty foods,
belching, and
flatulence (passing gas or farting).

Doctor’s perspective – Why do you get gallstones?

The exact cause of gallstones cannot usually be determined. Here are the three possible causes of gallstones:

High cholesterol in the bile: Normally, the cholesterol excreted by the liver is digested and dissolved by the chemicals in the bile. If the liver excretes excess cholesterol, beyond what the bile can dissolve, the excess cholesterol may crystallize, forming stones.
High bilirubin in the bile: Bilirubin is a chemical that's produced when the body breaks down red blood cells. Certain conditions of the liver like liver cirrhosis, liver infections or blood disorders cause increased production of bilirubin. The excess bilirubin can lead to gallstone formation.
Decreased gallbladder emptying: If the gallbladder doesn't empty completely, bile concentration may increase, contributing to the formation of gallstones.

Gallbladder Attack Symptoms

Symptoms of a gallbladder attack include:

pain in the upper right side or middle of the abdomen;
the pain may be dull, sharp, or cramping;
the pain typically starts suddenly;
the pain is steady and may spread to the back or the area below the right shoulder blade.

A male adult pointing to a liver outline and painted a gallbladder on his abdomen.Source: iStock

Gallstone definition and facts

Gallstones are "stones" that form in the gallbladder or bile ducts. The common types of gallstones are cholesterol, black pigment, and brown pigment.
The most common symptoms of gallstones are biliary colic and cholecystitis; however, usually, gallstones cause no symptoms.
The pain from biliary colic is a very specific type that comes on suddenly or rapidly and builds to a peak over a few minutes; however, the pain may vary in severity. The movement does not make the pain worse.
Other signs and symptoms of biliary colic include:
- Nausea
- Pain commonly felt in the upper abdomen
- Rarely, pain may be felt under the sternum and is mistaken for a heart attack or angina (chest pain).
- Biliary colic usually has a pattern that varies from person to person.
Gallstones do not cause intolerance to fatty foods, belching, abdominal distention, or gas.
Complications of gallstones include cholangitis, gangrene of the gallbladder, jaundice, pancreatitis, sepsis, fistula, and ileus.
Gallbladder sludge is associated with symptoms and complications of gallstones; however, like gallstones, sludge usually does not cause problems.
The best single test for diagnosing gallstones is transabdominal ultrasonography. Other tests include endoscopic ultrasonography, magnetic resonance cholangiopancreatography (MRCP), cholescintigraphy (HIDA scan), endoscopic retrograde cholangiopancreatography (ERCP), liver and pancreatic blood tests, duodenal drainage, oral cholecystogram (OCG), and intravenous cholangiogram (IVC).
Gallstones are managed primarily with observation (no treatment) or removal of the gallbladder (cholecystectomy). Less commonly used treatments include sphincterotomy and extraction of gallstones, dissolution with oral medications, and extracorporeal shock-wave lithotripsy (ESWL). Prevention of cholesterol gallstones also is possible with oral medications.
Symptoms of gallstones should stop the following cholecystectomy. If they do not, it is likely that gallstones were left in the ducts, there is a second problem within the bile ducts, or the symptoms are caused by another problem.
Many dietary recommendations have been made for the prevention or treatment of gallstones and to prevent their symptoms, but none of them have been shown to be effective.
Many home remedies have been suggested for eliminating gallstones, but none have been shown to be effective
Continuing research is directed at uncovering the genes that are responsible for the formation of gallstones.

Illustration of the digestive system with gallstones and close up of gallstones in the gallbladder a stone that has also passed into the cystic duct.Source: MedicineNet / Getty Images

What are gallstones? How do they form?

Gallstones (often misspelled as gall stones) are stones that form in the gall (bile) within the gallbladder. (The gallbladder is a pear-shaped organ just below the liver that stores bile secreted by the liver.) Gallstones reach a size of between a sixteenth of an inch and several inches.

Bile is a watery liquid made by the cells of the liver that is important for digesting food in the intestine, particularly fat, and eliminating toxic substances from the body.
Liver cells secrete the bile into small canals within the liver referred to as canaliculi.
The bile flows through the canaliculi and into larger collecting ducts within the liver referred to as intrahepatic bile ducts.
The bile then flows through merged intrahepatic bile ducts out of the liver as extrahepatic (outside the liver) bile ducts, ( first into the two hepatic bile ducts, then into the single common hepatic duct, and finally, after the common hepatic duct is joined by the cystic duct coming from the gallbladder, into the common bile duct.

From the bile duct, bile can flow from two different directions.

The first direction is through the common bile duct and directly into the intestine where the bile mixes with food and promotes digestion of food. At the same time, toxic substances that are removed by the liver from the blood are eliminated into the intestine.
The second direction is into an offshoot of the common bile duct, the cystic duct, and from there into the gallbladder.

Once in the gallbladder, bile is concentrated by the removal (absorption) of water. During a meal, the muscle that makes up the wall of the gallbladder contracts and squeezes the concentrated bile in the gallbladder back through the cystic duct into the common bile duct and then into the intestine. (Concentrated bile is much more effective for digestion than the un-concentrated bile that goes from the liver straight into the intestine.) The timing of gallbladder contraction – during a meal – allows the concentrated bile from the gallbladder to mix with food.

Gallstones usually form in the gallbladder; however, they also may form anywhere there is bile – in the intrahepatic, hepatic, common bile, and cystic ducts.

Gallstones also may move about in the bile, for example, from the gallbladder into the cystic or the common duct.

Illustration showing gallstones in the gallbladder as well as in the distal common bile duct. The common bile duct has a muscular wall.Source: Getty Images

Can you still have gallstones symptoms after they have been removed?

Removal of the gallbladder (cholecystectomy) should eliminate all gallstone-related symptoms except in three situations:

gallstones were left in the ducts,
there were problems with the bile ducts in addition to gallstones, and
gallstones were not the cause of the symptoms.

The possibility of gallstones in the ducts can be pursued with MRCP, endoscopic ultrasound, and ERCP. Rarely, gallstone-like symptoms can be caused by a condition called sphincter of Oddi dysfunction, discussed below.

The common bile duct has a muscular wall. The last several centimeters of the common bile duct's muscle immediately before the duct joins the duodenum comprise the sphincter of Oddi. The sphincter of Oddi controls the flow of bile. Since the pancreatic duct usually joins the common bile duct shortly before it enters the duodenum, the sphincter also controls the flow of fluid from the pancreatic duct. When the muscle of the sphincter tightens, it shuts off the flow of bile and pancreatic fluid. When it relaxes, bile and pancreatic fluid again flow into the duodenum, for example, after a meal. The sphincter may become scarred, and the duct is narrowed by the scarring. (The cause of the scarring is unknown.) The sphincter also may go into spasm intermittently. In either case, the flow of bile and pancreatic fluid may intermittently stop abruptly, mimicking the effects of a gallstone causing biliary colic and pancreatitis.

The diagnosis of sphincter of Oddi dysfunction can be difficult to make. The best diagnostic test requires an endoscopic procedure with the same type of endoscope as ERCP. Instead of filling the ducts with dye, however, the pressure within the sphincter is measured. If the pressure is abnormally high, scarring or spasm of the sphincter are likely. The treatment for sphincter of Oddi dysfunction is sphincterotomy (described previously). The measurement of liver and pancreatic enzymes in the blood also may be useful in diagnosing sphincter dysfunction.

Collection of gallstones of various sizes and shapes.Source: Getty Images

What do gallstones look like?

Gallstones may number anywhere from one to hundreds, varying in size from a millimeter to four or five centimeters. When there are single or only a few gallstones they tend to be round. When larger numbers of gallstones are present, they tend to be faceted due to the rubbing of one gallstone against another. Brown pigment gallstones may be crumbly and irregular.

Do gallstones pass?

Gallstones may pass out of the gallbladder or ducts particularly if they are small. It is the passage of gallstones that leads to many of their complications.

What causes gallstones? Who gets them?

Gallstones are common; they occur in approximately 20% of women in the US, Canada and Europe, but there is a large variation in the prevalence among different ethnic groups. For example, gallstones occur 1 ½ to 2 times more commonly in Scandinavians and Mexican-Americans. Among American Indians, gallstone prevalence is more than 80%. These differences probably are accounted for by genetic (hereditary) factors. First-degree relatives (parents, siblings, and children) of individuals with gallstones are 1 ½ times more likely to have gallstones than if they do not have a first-degree relative with gallstones. Further support for a genetic predisposition comes from twin studies. Thus, among non-identical pairs of twins (who share 50% of their genes with one another), both individuals in a pair have gallstones 8% of the time. Among identical pairs of twins (who share 100% of their genes with one another), both individuals have gallstones 23% of the time.

Several conditions are associated with the formation of gallstones, and the way in which they cause gallstones can vary. (See risks of gallstones.)

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Small gallstones made up largely of cholesterol.
Cholesterol gallstones are primarily made up of cholesterol. There are two other processes that promote the formation of cholesterol gallstonesSource: Getty Images

Cholesterol gallstones

There are several types of gallstones, and each type has a different cause.

Cholesterol gallstones

Cholesterol gallstones are primarily made up of cholesterol. They are the most common type of gallstone, comprising 80% of gallstones in individuals in Europe and the Americas. Cholesterol is one of the substances (chemicals) that liver cells secrete into bile. Secretion of cholesterol into bile is an important mechanism by which the liver eliminates excess cholesterol from the body.

In order for bile to carry cholesterol, the cholesterol must be dissolved in the bile. Cholesterol is fat, however, and bile is an aqueous or watery solution; fats do not dissolve in watery solutions. In order to make the cholesterol dissolve in bile, the liver also secretes two detergents, bile acids, and lecithin, into the bile. These detergents, just like dishwashing detergents, dissolve the fatty cholesterol so that it can be carried by bile through the ducts. If the liver secretes too much cholesterol for the number of bile acids and lecithin it secretes, some of the cholesterol does not stay dissolved. Similarly, if the liver does not secrete enough bile acids and lecithin, some of the cholesterol does not stay dissolved. In either case, the undissolved cholesterol sticks together and forms particles of cholesterol that grow in size and eventually become gallstones.

Two other processes promote the formation of cholesterol gallstones though neither process is able to cause cholesterol gallstones to form.

The first is an abnormally rapid formation and growth of cholesterol particles into gallstones. Thus, with the same concentrations of cholesterol, bile acids, and lecithin in the bile, patients with gallstones form particles of cholesterol more rapidly than individuals without gallstones.
The second process that promotes the formation and growth of gallstones is reduced contraction and emptying of the gallbladder that allows bile to stay in the gallbladder longer than normal so that there is more time for cholesterol particles to form and grow into gallstones.

QUESTION

What are symptoms of gallstones?
See Answer

Gallbladder opened to show numerous pigmented gallstones.
Pigment gallstones are the second most common type of gallstone.Source: Wikipedia – Gallstones

Pigment and antibiotic caused gallstones

Pigment gallstones

Pigment gallstones are the second most common type of gallstone. Although pigment gallstones comprise only 15% of gallstones in individuals from Europe and the Americas, they are more common than cholesterol gallstones in Southeast Asia. There are two types of pigment gallstones 1) black pigment gallstones, and 2) brown pigment gallstones.

The pigment is a waste product formed from hemoglobin, the oxygen-carrying chemical in red blood cells. The hemoglobin from old red blood cells that are being destroyed is changed into a chemical called bilirubin and released into the blood. Bilirubin is removed from the blood by the liver. The liver modifies the bilirubin and secretes the modified bilirubin into bile so that it can be eliminated from the body.

Black pigment gallstones: If there is too much bilirubin in the bile, the bilirubin combines with other constituents in bile, for example, calcium, to form pigment (so-called because it is dark brown in color). Pigment dissolves poorly in bile and, like cholesterol, it sticks together and forms particles that grow in size and eventually become gallstones. The pigment gallstones that form in this manner are called black pigment gallstones because they are black and hard.

Brown pigment gallstones: If there is a reduced contraction of the gallbladder or obstruction to the flow of bile through the ducts, bacteria may ascend from the duodenum into the bile ducts and gallbladder. The bacteria alter the bilirubin in the ducts and gallbladder, and the altered bilirubin then combines with calcium to form pigment. The pigment then combines with fats in bile (cholesterol and fatty acids from lecithin) to form particles that grow into gallstones. This type of gallstone is called a brown pigment gallstone because it is more brown than black. It also is softer than black pigment gallstones.

Other types of gallstones. Other types of gallstones are rare. Perhaps the most interesting type is the gallstone that forms in patients taking the antibiotic, ceftriaxone (Rocephin). Ceftriaxone is unusual in that it is eliminated from the body in bile in high concentrations. It combines with calcium in bile and becomes insoluble. Like cholesterol and pigment, the insoluble ceftriaxone and calcium form particles that grow into gallstones. Fortunately, most of these gallstones disappear once the antibiotic is discontinued; however, they still may cause problems until they disappear. Another rare type of gallstone is formed from calcium carbonate.

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A senior woman, a weight scale, a pregnant woman, and blood test tubes.
The eight risk factors for developing cholesterol gallstones include gender, age, obesity, pregnancy, birth control pills and hormone therapy, rapid weight loss, Crohn’s disease, and increased blood triglycerides.Source: iStock

Who is at risk of gallstones?

Risk for cholesterol gallstones

There is no relationship between cholesterol in the blood and cholesterol gallstones. Individuals with elevated blood cholesterol do not have an increased prevalence of cholesterol gallstones. A common misconception is that diet is responsible for the development of cholesterol gallstones, however, it isn't. The eight risk factors for developing cholesterol gallstones include:

Gender. Gallstones occur more commonly in women than men.
Age. Gallstone prevalence increases with age.
Obesity. Obese individuals are more likely to form gallstones than thin individuals.
Pregnancy. Pregnancy increases the risk for cholesterol gallstones because, during pregnancy, bile contains more cholesterol, and the gallbladder does not contract normally. This change in the composition of bile during pregnancy is due to the hormonal changes that occur during pregnancy. Gallstones that form during pregnancy may remain following the pregnancy or may dissolve once the composition of bile has returned to the nonpregnant state.
Birth control pills and hormone therapy Increased levels of hormones caused by either treatment mimics pregnancy.
Rapid weight loss. Rapid weight loss by whatever means, whether it is a very low-calorie diet or obesity surgery, causes cholesterol gallstones in up to 50% of individuals. Many of the gallstones will disappear after the weight is lost, but many do not. Moreover, until they are gone, they may cause problems.
Crohn's disease. Individuals with Crohn's disease of the ileum are more likely to develop gallstones. Gallstones form because patients with Crohn's disease lack enough bile acids to solubilize the cholesterol in bile. Normally, bile acids that enter the small intestine from the liver and gallbladder are absorbed back into the body and are secreted again by the liver into bile. In other words, the bile acids recycle. In Crohn's disease, the ileum is diseased. Bile acids are not absorbed normally, the body becomes depleted of bile acids, and fewer bile acids are secreted in bile. As a result, there are not enough detergent bile acids to keep cholesterol dissolved in the bile, resulting in gallstone formation.
Increased blood triglycerides. Gallstones occur more frequently in individuals with elevated blood triglyceride levels. The reason for this is unclear.

The risk for pigment gallstones

Black pigment gallstones form whenever an increased load of bilirubin reaches the liver. This occurs when there is increased destruction of red blood cells, as in diseases such as sickle cell disease and thalassemia. Black pigment gallstones also are more common in patients with cirrhosis of the liver.
Brown pigment gallstones form when there is stasis of bile (decreased flow), for example, when there are narrowed or obstructed bile ducts.

A female doctor sits next to an ultrasound machine.Source: iStock

Diagnosis with transabdominal and ultrasonography

Gallstones are diagnosed in one of two situations.

When some symptoms or signs suggest the presence of gallstones and the diagnosis of gallstones is being pursued.
Coincidentally while a non-gallstone-related medical problem is being evaluated.

Ultrasonography is the most important means of diagnosing gallstones. Standard computerized tomography (CT or CAT scan) and magnetic resonance imaging (MRI) may occasionally demonstrate gallstones; however, they are not as useful compared to ultrasonography because they miss gallstones.

Ultrasonography

Ultrasonography is a radiological technique that uses high-frequency sound waves to produce images of the organs and structures of the body. The sound waves are emitted from a device called a transducer and are sent through the body's tissues. The sound waves are reflected by the surfaces and interiors of internal organs and structures as "echoes." These echoes return to the transducer and are transmitted onto a viewing monitor. On the monitor, the outline of organs and structures can be determined as well as their consistency, for example, liquid or solid.

Two types of ultrasonographic techniques can be used for diagnosing gallstones: transabdominal ultrasonography and endoscopic ultrasonography.

Transabdominal ultrasonography

For transabdominal ultrasonography, the transducer is placed directly on the skin of the abdomen. The sound waves travel through the skin and then into the abdominal organs. Transabdominal ultrasonography is painless, inexpensive, and without risk to the patient. In addition to identifying 97% of gallstones in the gallbladder, abdominal ultrasonography can identify many other abnormalities related to gallstones. It can identify:

A thickened wall of the gallbladder when there are cholecystitis and inflammation has thickened the wall
Enlarged gallbladder and bile duct due to obstruction by gallstones
Pancreatitis
Fluid surrounding the gallbladder (a possible sign of inflammation) sludge

Transabdominal ultrasonography also may identify diseases not related to gallstones that may be the cause of the patient's problem, for example, appendicitis. The limitations of transabdominal ultrasonography are that it can only identify gallstones larger than 4-5 millimeters in size, and it is poor at identifying gallstones in the bile ducts.

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A doctor discusses gallstone prevention and possible after-effects of removal with a patient in the hospital. Current scientific studies are directed at uncovering the specific genes that are responsible for gallstones.Source: Getty Images

Which types of doctors treat gallstones?

Gallstones usually are diagnosed by a gastroenterologist, a medical subspecialist who deals with diseases of the intestine, liver, pancreas, and gallbladder. General surgeons also may be involved in the diagnosis of gallstones but usually are the doctors who treat gallstones because the common treatment is surgical removal of the gallbladder.

What’s new with gallstone causes and treatments?

It is clear that genetic factors are important in determining who develops gallstones. Current scientific studies are directed at uncovering the specific genes that are responsible for gallstones. To date, 8-10 genes have been identified as being associated with cholesterol gallstones, at least in animals that develop cholesterol gallstones. Not surprisingly, the products of many of these genes control the production and secretion (by the liver) of cholesterol, bile acids, and lecithin. The long-term goal is to be able to identify individuals who are genetically at very high risk for cholesterol gallstones and to offer them preventive treatment. An understanding of the exact mechanism(s) of gallstone formation also may result in new therapies for treatment and prevention.

Surgery for gallstones has undergone a major transition from requiring large abdominal incisions to requiring only tiny incisions for laparoscopic instruments (laparoscopic cholecystectomy). It is possible that there will be another transition. Surgeons are experimenting with a technique called natural orifice transluminal endoscopic surgery (NOTES). NOTES is a new technique for accomplishing standard intra-abdominal surgery, but access to the abdomen is through a natural orifice – the mouth, anus, or vagina.

For NOTES, a flexible endoscopic instrument is similar to the flexible endoscopes presently being used widely is introduced through the chosen orifice, through an incision somewhere inside the orifice (for example, the stomach), and into the abdominal cavity. Thus, the only incision is within the body and not visible on the body's surface. There are potential advantages to this type of surgery, but it is in the early stages of development, and it is unclear what the future role of NOTES will be in gallbladder surgery. Nevertheless, several series of patients have already been described who have had their gallbladders removed via NOTES primarily through the vagina.

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