Gallstones

National Digestive Diseases Information Clearinghouse

What are gallstones?

Gallstonesarehardparticlesthatdevelopin
thegallbladder. Thegallbladderisasmall,
pear-shapedorganlocatedintheupperright
abdomentheareabetweenthechestand
hipsbelowtheliver.
Gallstonescanrangeinsizefromagrain
ofsandtoagolfball. Thegallbladdercan
developasinglelargegallstone,hundredsof
tinystones,orbothsmallandlargestones.
Gallstonescancausesuddenpaininthe
upperrightabdomen. Thispain,calleda
gallbladderattackorbiliarycolic,occurs
whengallstonesblocktheductsofthebiliary
tract.
What is the biliary tract?
Thebiliarytractconsistsofthegallbladder
andthebileducts. Thebileductscarrybile
andotherdigestiveenzymesfromtheliver
andpancreastotheduodenumtherst
partofthesmallintestine.
Theliverproducesbileauidthatcarries
toxinsandwasteproductsoutofthebody
andhelpsthebodydigestfatsandthe
fat-solublevitaminsA,D,E,andK. Bile
mostlyconsistsofcholesterol,bilesalts,
andbilirubin. Bilirubin,areddish-yellow
substance,formswhenhemoglobinfromred
bloodcellsbreaksdown. Mostbilirubinis
excretedthroughbile.
Gallbladder
Gallbladder
Duodenum
Hepatic ducts
Cystic duct
Pancreas
Common bile duct
Pancreatic duct
Liver
Liver
Thebiliarytract

Thebileductsofthebiliarytractinclude
thehepaticducts,thecommonbileduct,
thepancreaticduct,andthecysticduct.
Thegallbladderstoresbile. Eatingsignals
thegallbladdertocontractandemptybile
throughthecysticductandcommonbile
ductintotheduodenumtomixwithfood.
What causes gallstones?
Imbalancesinthesubstancesthatmakeup
bilecausegallstones. Gallstonesmayform
ifbilecontainstoomuchcholesterol,too
muchbilirubin,ornotenoughbilesalts.
Scientistsdonotfullyunderstandwhythese
imbalancesoccur. Gallstonesalsomayform
ifthegallbladderdoesnotemptycompletely
oroftenenough.
Thetwotypesofgallstonesarecholesterol
andpigmentstones:
Cholesterolstones,usuallyyellow-green
incolor,consistprimarilyofhardened
cholesterol. IntheUnitedStates,
morethan80percentofgallstonesare
cholesterolstones.
1
Pigmentstones,darkincolor,aremade
ofbilirubin.
Who is at risk for gallstones?
Certainpeoplehaveahigherriskof
developinggallstonesthanothers:
2
Womenaremorelikelytodevelop
gallstonesthanmen. Extraestrogen
canincreasecholesterollevelsinbile
anddecreasegallbladdercontractions,
whichmaycausegallstonestoform.
Womenmayhaveextraestrogendue
topregnancy,hormonereplacement
therapy,orbirthcontrolpills.
Peopleoverage40aremorelikelyto
developgallstonesthanyoungerpeople.
Peoplewithafamilyhistoryof
gallstoneshaveahigherrisk.
AmericanIndianshavegeneticfactors
thatincreasetheamountofcholesterol
intheirbile. Infact,AmericanIndians
havethehighestrateofgallstonesin
theUnitedStatesalmost65percent
ofwomenand30percentofmenhave
gallstones.
MexicanAmericansareathigherriskof
developinggallstones.
2 Gallstones

Otherfactorsthataffectapersonsriskof
gallstonesinclude
2

Obesity.Peoplewhoareobese,especially
women,haveincreasedriskofdeveloping
gallstones. Obesityincreasestheamount
ofcholesterolinbile,whichcancause
stoneformation.
Rapidweightloss. Asthebodybreaks
downfatduringprolongedfastingand
rapidweightloss,theliversecretesextra
cholesterolintobile. Rapidweightloss
canalsopreventthegallbladderfrom
emptyingproperly. Low-caloriediets
andbariatricsurgerysurgerythat
limitstheamountoffoodapersoncan
eatordigestleadtorapidweightloss
andincreasedriskofgallstones.
Diet.Researchsuggestsdietshigh
incaloriesandrenedcarbohydrates
andlowinberincreasetheriskof
gallstones. Renedcarbohydratesare
grainsprocessedtoremovebranand
germ,whichcontainnutrientsandber.
Examplesofrenedcarbohydrates
includewhitebreadandwhiterice.
Certainintestinaldiseases. Diseases
thataffectnormalabsorptionof
nutrients,suchasCrohnsdisease,are
associatedwithgallstones.
Metabolicsyndrome,diabetes,and
insulinresistance. Theseconditions
increasetheriskofgallstones.
Metabolicsyndromealsoincreases
theriskofgallstonecomplications.
Metabolicsyndromeisagroupoftraits
andmedicalconditionslinkedtobeing
overweightorobesethatputspeople
atriskforheartdiseaseandtype2
diabetes.
Readmoreabouttheseconditionsin
Insulin Resistance and Prediabetesat
www.diabetes.niddk.nih.gov.
Pigmentstonestendtodevelopinpeople
whohave
cirrhosisaconditioninwhichtheliver
slowlydeterioratesandmalfunctions
duetochronic,orlonglasting,injury
infectionsinthebileducts
severehemolyticanemiasconditions
inwhichredbloodcellsarecontinuously
brokendown,suchassicklecellanemia
3 Gallstones

What are the symptoms and
complications of gallstones?
Manypeoplewithgallstonesdonothave
symptoms. Gallstonesthatdonotcause
symptomsarecalledasymptomatic,orsilent,
gallstones. Silentgallstonesdonotinterfere
withthefunctionofthegallbladder,liver,or
pancreas.
Ifgallstonesblockthebileducts,pressure
increasesinthegallbladder,causinga
gallbladderattack. Thepainusuallylasts
from1toseveralhours.
1
Gallbladderattacks
oftenfollowheavymeals,andtheyusually
occurintheeveningorduringthenight.
Gallbladderattacksusuallystopwhen
gallstonesmoveandnolongerblockthe
bileducts. However,ifanyofthebileducts
remainblockedformorethanafewhours,
complicationscanoccur. Complications
includeinammation,orswelling,ofthe
gallbladderandseveredamageorinfection
ofthegallbladder,bileducts,orliver.
Agallstonethatbecomeslodgedinthe
commonbileductneartheduodenum
andblocksthepancreaticductcancause
gallstonepancreatitisinammationofthe
pancreas.
Leftuntreated,blockagesofthebileductsor
pancreaticductcanbefatal.
When should a person talk
with a health care provider
about gallstones?
Peoplewhothinktheyhavehadagallbladder
attackshouldnotifytheirhealthcare
provider. Althoughtheseattacksusually
resolveasgallstonesmove,complicationscan
developifthebileductsremainblocked.
Peoplewithanyofthefollowingsymptoms
duringorafteragallbladderattackshould
seeahealthcareproviderimmediately:
abdominalpainlastingmorethan
5hours
nauseaandvomiting
feverevenalow-gradefeverorchills
yellowishcoloroftheskinorwhitesof
theeyes,calledjaundice
tea-coloredurineandlight-colored
stools
Thesesymptomsmaybesignsofserious
infectionorinammationofthegallbladder,
liver,orpancreas.
4 Gallstones

How are gallstones

diagnosed?
Ahealthcareproviderwillusuallyorder
anultrasoundexamtodiagnosegallstones.
Otherimagingtestsmayalsobeused.
Ultrasoundexam. Ultrasounduses
adevice,calledatransducer,that
bouncessafe,painlesssoundwaves
offorganstocreateanimageoftheir
structure. Aspeciallytrainedtechnician
performstheprocedureinahealthcare
providersofce,outpatientcenter,or
hospital,andaradiologistadoctor
whospecializesinmedicalimaging
interpretstheimages. Anesthesiaisnot
needed. Ifgallstonesarepresent,they
willbevisibleintheimage. Ultrasound
isthemostaccuratemethodtodetect
gallstones.
Computerizedtomography(CT)scan.
ACTscanisanxraythatproduces
picturesofthebody. ACTscanmay
includetheinjectionofaspecialdye,
calledcontrastmedium. CTscansuse
acombinationofxraysandcomputer
technologytocreatethree-dimensional
(3-D)images. CTscansrequirethe
persontolieonatablethatslides
intoatunnel-shapeddevicewherethe
xraysaretaken.Anx-raytechnician
performstheprocedureinanoutpatient
centerorhospital,andaradiologist
interpretstheimages. Anesthesiaisnot
needed. CTscanscanshowgallstones
orcomplications,suchasinfection
andblockageofthegallbladderorbile
ducts. However,CTscanscanmiss
gallstonesthatarepresent.
Magneticresonanceimaging(MRI).
MRImachinesuseradiowavesand
magnetstoproducedetailedpictures
ofthebodysinternalorgansand
softtissueswithoutusingxrays. A
speciallytrainedtechnicianperforms
theprocedureinanoutpatientcenter
orhospital,andaradiologistinterprets
theimages. Anesthesiaisnotneeded,
thoughpeoplewithafearofconned
spacesmayreceivelightsedation. An
MRImayincludetheinjectionof
contrastmedium. WithmostMRI
machines,thepersonliesonatable
thatslidesintoatunnel-shapeddevice
thatmaybeopenendedorclosedat
oneend;somenewermachinesallow
thepersontolieinamoreopenspace.
MRIscanshowgallstonesintheducts
ofthebiliarysystem.
Cholescintigraphy. Cholescintigraphy
alsocalledahydroxyliminodiacetic
acidscan,HIDAscan,orhepatobiliary
scanusesanunharmfulradioactive
materialtoproducepicturesofthe
biliarysystem. Incholescintigraphy,
thepersonliesonanexamtableand
ahealthcareproviderinjectsasmall
amountofunharmfulradioactive
materialintoaveininthepersons
arm. Thehealthcareprovidermay
alsoinjectasubstancethatcauses
thegallbladdertocontract. Aspecial
cameratakespicturesoftheradioactive
materialasitmovesthroughthebiliary
system. Aspeciallytrainedtechnician
performstheprocedureinanoutpatient
centerorhospital,andaradiologist
interpretstheimages. Anesthesiaisnot
needed. Cholescintigraphyisusedto
diagnoseabnormalcontractionsofthe
gallbladderorobstructionofthebile
ducts.
5 Gallstones

Endoscopicretrograde
cholangiopancreatography(ERCP).
ERCPusesanxraytolookintothe
bileandpancreaticducts. Afterlightly
sedatingtheperson,thehealthcare
providerinsertsanendoscopeasmall,
exibletubewithalightandacamera
ontheendthroughthemouthinto
theduodenumandbileducts. The
endoscopeisconnectedtoacomputer
andvideomonitor. Thehealthcare
providerinjectscontrastmedium
throughthetubeintothebileducts,
whichmakestheductsshowuponthe
monitor. Thehealthcareprovider
performstheprocedureinanoutpatient
centerorhospital. ERCPhelpsthe
healthcareproviderlocatetheaffected
bileductandthegallstone. Thestone
iscapturedinatinybasketattachedto
theendoscopeandremoved. Thistest
ismoreinvasivethanothertestsandis
usedselectively.
Healthcareprovidersalsousebloodteststo
lookforsignsofinfectionorinammation
ofthebileducts,gallbladder,pancreas,or
liver. Abloodtestinvolvesdrawingbloodat
ahealthcareprovidersofceorcommercial
facilityandsendingthesampletoalabfor
analysis.
Gallstonesymptomsmaybesimilartothose
ofotherconditions,suchasappendicitis,
ulcers,pancreatitis,andgastroesophageal
reuxdisease.
Sometimes,silentgallstonesarefoundwhen
apersondoesnothaveanysymptoms. For
example,ahealthcareprovidermaynotice
gallstoneswhenperformingultrasoundfora
differentreason.
How are gallstones treated?
Ifgallstonesarenotcausingsymptoms,
treatmentisusuallynotneeded. However,
ifapersonhasagallbladderattackorother
symptoms,ahealthcareproviderwillusually
recommendtreatment. Apersonmaybe
referredtoagastroenterologistadoctor
whospecializesindigestivediseases
fortreatment. Ifapersonhashadone
gallbladderattack,moreepisodeswilllikely
follow.
Theusualtreatmentforgallstonesis
surgerytoremovethegallbladder. Ifa
personcannotundergosurgery,nonsurgical
treatmentsmaybeusedtodissolve
cholesterolgallstones. Ahealthcare
providermayuseERCPtoremovestones
inpeoplewhocannotundergosurgeryorto
removestonesfromthecommonbileduct
inpeoplewhoareabouttohavegallbladder
removalsurgery.
Surgery
Surgerytoremovethegallbladder,called
cholecystectomy,isoneofthemostcommon
operationsperformedonadultsinthe
UnitedStates.
Thegallbladderisnotanessentialorgan,
whichmeansapersoncanlivenormally
withoutagallbladder. Oncethegallbladder
isremoved,bileowsoutoftheliverthrough
thehepaticandcommonbileductsand
directlyintotheduodenum,insteadofbeing
storedinthegallbladder.
6 Gallstones

Surgeonsperformtwotypesof
cholecystectomy:
Laparoscopiccholecystectomy. In
alaparoscopiccholecystectomy,
thesurgeonmakesseveraltiny
incisionsintheabdomenandinserts
alaparoscopeathintubewithatiny
videocameraattached. Thecamera
sendsamagniedimagefrominside
thebodytoavideomonitor,giving
thesurgeonaclose-upviewoforgans
andtissues. Whilewatchingthe
monitor,thesurgeonusesinstruments
tocarefullyseparatethegallbladder
fromtheliver,bileducts,andother
structures. Thenthesurgeonremoves
thegallbladderthroughoneofthe
smallincisions. Patientsusuallyreceive
generalanesthesia.
Mostcholecystectomiesareperformed
withlaparoscopy. Manylaparoscopic
cholecystectomiesareperformedonan
outpatientbasis,meaningthepersonis
abletogohomethesameday. Normal
physicalactivitycanusuallyberesumed
inaboutaweek.
3
Opencholecystectomy. Anopen
cholecystectomyisperformedwhen
thegallbladderisseverelyinamed,
infected,orscarredfromother
operations. Inmostofthesecases,
opencholecystectomyisplannedfrom
thestart. However,asurgeonmay
performanopencholecystectomywhen
problemsoccurduringalaparoscopic
cholecystectomy. Inthesecases,
thesurgeonmustswitchtoopen
cholecystectomyasasafetymeasurefor
thepatient.
Toperformanopencholecystectomy,
thesurgeoncreatesanincisionabout
4to6incheslongintheabdomento
removethegallbladder.
4
Patients
usuallyreceivegeneralanesthesia.
Recoveryfromopencholecystectomy
mayrequiresomepeopletostayin
thehospitalforuptoaweek. Normal
physicalactivitycanusuallyberesumed
afteraboutamonth.
3
Asmallnumberofpeoplehavesofterand
morefrequentstoolsaftergallbladder
removalbecausebileowsintothe
duodenummoreoften. Changesinbowel
habitsareusuallytemporary;however,
theyshouldbediscussedwithahealthcare
provider.
Thoughcomplicationsfromgallbladder
surgeryarerare,themostcommon
complicationisinjurytothebileducts. An
injuredcommonbileductcanleakbile
andcauseapainfulandpossiblydangerous
infection. Oneormoreadditional
operationsmaybeneededtorepairthebile
ducts. Bileductinjuriesoccurinlessthan
1percentofcholecystectomies.
5
7 Gallstones

Nonsurgical Treatments for
Cholesterol Gallstones
Nonsurgicaltreatmentsareusedonlyin
specialsituations,suchaswhenaperson
withcholesterolstoneshasaseriousmedical
conditionthatpreventssurgery. Gallstones
oftenrecurwithin5yearsafternonsurgical
treatment.
6
Twotypesofnonsurgicaltreatmentscanbe
usedtodissolvecholesterolgallstones:
Oraldissolutiontherapy. Ursodiol
(Actigall)andchenodiol(Chenix)are
medicationsthatcontainbileacids
thatcandissolvegallstones. These
medicationsaremosteffectivein
dissolvingsmallcholesterolstones.
Monthsoryearsoftreatmentmaybe
neededtodissolveallstones.
Shockwavelithotripsy. Amachine
calledalithotripterisusedtocrushthe
gallstone. Thelithotriptergenerates
shockwavesthatpassthroughthe
personsbodytobreakthegallstone
intosmallerpieces. Thisprocedureis
usedonlyrarelyandmaybeusedalong
withursodiol.
Eating, Diet, and Nutrition
Factorsrelatedtoeating,diet,andnutrition
thatincreasetheriskofgallstonesinclude
obesity
rapidweightloss
dietshighincaloriesandrened
carbohydratesandlowinber
Peoplecandecreasetheirriskofgallstones
bymaintainingahealthyweightthrough
properdietandnutrition.
Ursodiolcanhelppreventgallstonesin
peoplewhorapidlyloseweightthrough
low-caloriedietsorbariatricsurgery. People
shouldtalkwiththeirhealthcareprovideror
dietitianaboutwhatdietisrightforthem.
8 Gallstones

Points to Remember
Gallstonesarehardparticlesthat
developinthegallbladder.
Imbalancesinthesubstancesthat
makeupbilecausegallstones.
Gallstonesmayformifbilecontains
toomuchcholesterol,toomuch
bilirubin,ornotenoughbilesalts.
Scientistsdonotfullyunderstandwhy
theseimbalancesoccur.
Women,peopleoverage40,people
withafamilyhistoryofgallstones,
AmericanIndians,andMexican
Americanshaveahigherriskof
developinggallstones.
Manypeoplewithgallstonesdonot
havesymptoms. Gallstonesthat
donotcausesymptomsarecalled
asymptomatic,orsilent,gallstones.
Ifgallstonesblockthebileducts,
pressureincreasesinthegallbladder,
causingagallbladderattack.
Gallbladderattacksoftenfollowheavy
meals,andtheyusuallyoccurinthe
eveningorduringthenight.
Gallstonesymptomsmaybesimilarto
thoseofotherconditions.
Ifgallstonesarenotcausing
symptoms,treatmentisusuallynot
needed. However,ifapersonhasa
gallbladderattackorothersymptoms,
ahealthcareproviderwillusually
recommendtreatment.
Theusualtreatmentforgallstones
issurgerytoremovethegallbladder.
Ifapersoncannotundergo
surgery,nonsurgicaltreatments
maybeusedtodissolvecholesterol
gallstones. Ahealthcareprovider
mayuseendoscopicretrograde
cholangiopancreatography(ERCP)to
removestonesinpeoplewhocannot
undergosurgeryortoremovestones
fromthecommonbileductinpeople
whoareabouttohavegallbladder
removalsurgery.
Thegallbladderisnotanessential
organ,whichmeansapersoncanlive
normallywithoutagallbladder. Once
thegallbladderisremoved,bileows
outoftheliverthroughthehepatic
andcommonbileductsanddirectly
intotheduodenum,insteadofbeing
storedinthegallbladder.
9 Gallstones

Hope through Research

TheDivisionofDigestiveDiseasesand
NutritionattheNationalInstituteof
DiabetesandDigestiveandKidneyDiseases
(NIDDK)supportsbasicandclinical
researchintogastrointestinaldiseases,
includinggallstones.
Clinicaltrialsareresearchstudiesinvolving
people. Clinicaltrialslookatsafeand
effectivenewwaystoprevent,detect,or
treatdisease. Researchersalsouseclinical
trialstolookatotheraspectsofcare,such
asimprovingthequalityoflifeforpeople
withchronicillnesses. Tolearnmoreabout
clinicaltrials,whytheymatter,andhowto
participate,visittheNIHClinicalResearch
TrialsandYouwebsiteatwww.nih.gov/health/
clinicaltrials.Forinformationaboutcurrent
studies,visitwww.ClinicalTrials.gov.
References
1. HeumanDM. Cholelithiasis. Medscape
website. http://emedicine.medscape.
com/article/175667-overview#showall.
UpdatedMay13,2013. Accessed
July23,2013.
2. StintonLM,ShafferEA. Epidemiology
ofgallbladderdisease: cholelithiasis
andcancer. Gut and Liver.
2012;6(2):172187.
3. SherwinterDA. Laparoscopic
cholecystectomy. Medscapewebsite.
http://emedicine.medscape.com/
article/1582292-overview. Updated
May10,2013. AccessedJuly23,2013.
4. HopeWW. Opencholecystectomy.
Medscapewebsite. http://emedicine.
medscape.com/article/1582261-
overview#showall. UpdatedJanuary8,
2013. AccessedJuly23,2013.
5. SahajpalAK,ChowSC,DixonE,Greig
PD,GallingerS,WeiAC.Bileduct
injuriesassociatedwithlaparoscopic
cholecystectomy: timingofrepairand
long-termoutcomes. Archives of Surgery.
2010;145(8):757763.
6. PortincasaP,CiaulaAD,Bonfrate
L,WangDQ.Therapyofgallstone
disease: whatitwas,whatitis,whatit
willbe. World Journal of Gastrointestinal
Pharmacology and Therapeutics.
2012;3(2):720.
10 Gallstones

For More Information

AmericanCollegeofGastroenterology
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Bethesda,MD 20827
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Internet: www.gi.org
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Fax:3016545920
Email: member@gastro.org
Internet: www.gastro.org
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11 Gallstones
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