Symptoms and management of gallstones

Mr Jonathan Wilson, Consultant Laparoscopic Colorectal and General Surgeon at The Whittington Hospital and The London Clinic, explains the symptoms of gallstones in detail and describes the diagnostic tests that you may have to confirm that your gallbladder needs to be removed. He also compares open gallbladder surgery with the newer laparoscopic technique, highlighting the benefits for patients.

Introduction to Gallstones and treatment

Gallstones are abnormal deposits that develop in the gallbladder, the small pouch that sits just under the liver. The gallbladder’s main function is to store bile, the bitter-tasting green fluid that is released into the small intestine to assist with fat digestion. The stones themselves can be small, large, numerous or there can just be one gallstone (this is known as a ‘solitaire’). Many people have them and never know as the stones do not cause problems.

When they do start to cause signs and symptoms, gallstones need to be removed, which almost always means removing the entire gallbladder. This is now done routinely using laparoscopic or keyhole surgery.

Understanding the symptoms that gallstones cause

The presence of stones in the gallbladder does not, in itself, cause pain or other symptoms. If a small stone attempts to exit the gallbladder and gets stuck either in the neck of the gallbladder or in the bile duct, the narrow tube that takes bile into the small intestine, this acts as an irritant. The muscular gallbladder attempts to unblock the system by rhythmically contracting and squeezing, causing colic. Inflammation of the gallbladder wall, a condition called cholecystitis, can then occur; the pain becomes more continuous and is often accompanied by systemic upset such as fever and dehydration. Associated symptoms include:

·         Biliary colic: severe pain in the upper right of the abdomen, just below the ribs. The pain often starts after eating a meal with a high fat content. It can radiate to the tip of the right shoulder blade and can persist for several hours. The longer the pain lasts, the more likely the gallbladder is to become inflamed.

·         Nausea: the pain of biliary colic can make you feel unwell.

·         Vomiting: in severe attacks, an attack of biliary colic can lead to vomiting. This is not usually prolonged and patients usually feel better when their digestive system is emptier.

·         Dehydration: if you are vomiting and you cannot keep any fluid down when you drink you can become dehydrated quite quickly. This can cause headaches, lethargy and disorientation.

·         Jaundice: when the bile duct becomes blocked, bile cannot escape. The pigments in bile, which are waste products produce by the liver, end up in the blood and turn the tissues yellow. This can be seen in the skin in severe cases but mild jaundice is usually only noticeable in the whites of the eyes. The urine may also turn dark brown and the stools become pale.

·         Inflammation of the pancreas: the bile duct and the pancreatic duct, the tube that leads from the pancreas into the small intestine, share a common exit point. A stone the gets stuck at this exit point can lead to inflammation of the pancreas. Severe pancreatitis is extremely serious and is associated with a mortality rate of 1 in 10.

Diagnostic tests that confirm gallstones

Upper abdominal pain, nausea and vomiting have many other causes such as viral gastritis, acid-related stomach problems, so an accurate diagnosis is essential.

The first port of call is your GP: he or she will want to ask you about when and how often your symptoms have occurred, along with any obvious precipitating or relieving factors. The location of pain and any radiation is important. You will probably also be referred to a Consultant General Surgeon or a Gastroenterologist for diagnostic tests and a specialist opinion.

A physical examination

Your own doctor will examine you to see if they can detect tenderness over your gallbladder. This is done by gently pressing on the upper right side abdomen, just under the ribcage. Your temperature will be taken and your heart rate will be measured.

Blood tests

Your GP will then arrange for your blood to be taken so that blood tests can be carried out to find out whether your liver has been affected (liver function tests), or if the gallbladder has become inflamed (white cell count and C-reactive protein [CRP] test). Pancreatitis can also be detected by measuring serum amylase.

An ultrasound scan

This will usually be performed in the hospital. An ultrasound investigation is a painless and very efficient way to detect the actual gallstones. It involves passing a jelly-lubricated probe over the abdominal wall and images can be viewed on a screen. Because they are hard and solid, the stones show up very well on the scan. This confirms the diagnosis and also informs the ultrasonographer of how many stones are present, how big they are and whether any stones are causing a blockage. The test takes about 15 minutes.

A cholangiogram

This is specific imaging to provide even more information about the position, number and size of the gallstones and to reveal the presence of stones in the bile duct. Nowadays this is performed as a non-invasive MRI scan (Magnetic Resonance Imaging) and is known as a MRCP (Magnetic Resonance Cholangio-Pancreatogram). This involves lying still and passing into a tunnelled machine, which takes detailed pictures of the inside of the abdomen.

If there is a stone in the bile duct, a more invasive ERCP (endoscopic retrograde cholangiopancreatogram) is required. In this test, a flexible camera is passed through the throat into your stomach under sedation, through to the exit point of the bile duct and small tools are used to release the blockage and free the stone.

Open surgery versus laparoscopic gallbladder removal

Thirty years ago, having your gallbladder removed meant a major open operation with three or four days in hospital and then recovery at home for several weeks. An open operation requires an incision that is typically 15 cm (6 inches) long; the surgeon needs to cut through the skin and underlying muscle to be able to access the gallbladder. These muscles take time to heal up and recovery can be quite painful.

Of the 60,000 people in the UK who have their gallbladders removed today, the majority have a laparoscopic operation known as a laparoscopic cholecystectomy. This is just as effective as the open operation but it is much easier to cope with. Your surgeon uses instruments with a camera inside your body, so no large incision is needed.

Typically, four small incisions, the majority less than 1cm, are made at different points in the abdomen to allow access for the instruments. While you are under general anaesthetic, your surgeon works using images relayed to a large screen in the operating theatre.

Evidence for the benefits of laparoscopic cholecystectomy

A meta-analysis, a large study looking at other research done over several years looked at the experiences and outcomes from over 5,000 patients who had either had open gallbladder surgery or laparoscopic surgery.

This provided strong evidence for the benefits of having laparoscopic gallbladder surgery:

  • Less pain after surgery. Open surgery requires strong painkillers in the first few days but after laparoscopic gallbladder surgery, most people need only paracetamol.
  • Much less time in hospital. If your operation is in the morning, you go home the same day. If it’s in the afternoon, you may need a one-night stay.
  • Less recovery time at home. Most people are back to light activities and can go back to work around 7-10 days later. Some discomfort can continue for a few weeks but taking over-the-counter painkillers can usually help you cope with this.
  • No big scar. The four small incisions heal up quickly and the smaller scars fade rapidly.
  • No increased risk of complications. Patients having laparoscopic surgery generally have a similar risk of bleeding or infection compared to patients having the more established open operation.

Laparoscopic gallbladder surgery is now accepted as the best option for most patients; if you are not suitable and need an open operation, your surgeon will explain why.

The part of the body that contains the stomach, intestines, liver, gallbladder and other organs. Full medical glossary
Relating to the abdomen, which is the region of the body between the chest and the pelvis. Full medical glossary
An enzyme that breaks starch down into sugar. Full medical glossary
A medication that reduces sensation. Full medical glossary
An X-ray image of the blood vessels following the injection of a dye to improve visibility. Full medical glossary
A fluid produced by the liver, which helps the fat ingested in food to combine with the digestive juices in the gut. Full medical glossary
Severe pain in the upper right-hand side of the abdomen usually caused by gallstones. Full medical glossary
The organ that stores urine. Full medical glossary
A fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. Full medical glossary
A protein found in the blood. Raised levels suggest tissue damage or necrosis (death of cells). Full medical glossary
The basic unit of all living organisms. Full medical glossary
The surgical removal of the gallbladder. Full medical glossary
Acute or chronic inflammation of the gallbladder causing severe abdominal pain. Full medical glossary
A severe spasmodic pain that occurs in waves of increasing intensity. Full medical glossary
A condition that is linked to, or is a consequence of, another disease or procedure. Full medical glossary
An abbreviation for C-reactive protein, found in the blood. Raised levels of this protein suggest tissue damage or necrosis (death of cells). Full medical glossary
A fluid-filled, enclosed pouch developing in a bodily structure as part of a disease process Full medical glossary
Inflammation of the bladder. Full medical glossary
Water deficiency in the body. Full medical glossary
The process of determining which condition a patient may have. Full medical glossary
An abbreviation for endoscopic retrograde cholangiopancreaticogram. Full medical glossary
One of the three main food constituents (with carbohydrate and protein), and the main form in which energy is stored in the body. Full medical glossary
The raising of the body temperature above norma, which may be accompanied by symptoms such as shivering, headache and sweating. Full medical glossary
A viral infection affecting the respiratory system. Full medical glossary
Small pear-shaped organ that sits under the liver and that stores bile. Full medical glossary
Lumps of solid matter found in the gallbladder. Full medical glossary
Inflammation of the stomach lining. Full medical glossary
The basic unit of genetic material carried on chromosomes. Full medical glossary
Invasion by organisms that may be harmful, for example bacteria or parasites. Full medical glossary
The body’s response to injury. Full medical glossary
The section of gut, or gastrointestinal tract, from the stomach to the anus. Full medical glossary
A term used to describe a yellow tinge to the skin and a yellowing of the whites of the eyes. It is caused by a build up of bilirubin in the blood. Full medical glossary
A type of minimally invasive surgery. Full medical glossary
A keyhole surgical procedure. Full medical glossary
A large abdominal organ that has many important roles including the production of bile and clotting factors, detoxification, and the metabolism of proteins, carbohydrates and fats. Full medical glossary
An abbreviation for magnetic resonance imaging, a technique for imaging the body that uses electromagnetic waves and a strong magnetic field. Full medical glossary
Tissue made up of cells that can contract to bring about movement. Full medical glossary
Any test or technique that does not involve penetration of the skin. The term 'non-invasive' may also describe tumours that do not invade surrounding tissues. Full medical glossary
A gland behind the stomach that produces digestive enzymes and the hormones insulin and glucagon, which together regulate glucose levels in the blood. Full medical glossary
A glandular organ that secretes digestive enzymes and hormones. Full medical glossary
Relating to the pancreas. Full medical glossary
Inflammation of the pancreas, a gland behind the stomach that produces digestive enzymes and the hormones insulin and glucagon. Full medical glossary
A craving to eat non-food substances such as earth or coal. Full medical glossary
Compounds that form the structure of muscles and other tissues in the body, as well as comprising enzymes and hormones. Full medical glossary
Energy in the form of waves or particles, including radio waves, X-rays and gamma rays. Full medical glossary
Relating to the rectum, the lowest part of the bowel leading to the anus. Full medical glossary
The clear fluid that separates from blood when it clots. It contains salts, glucose and proteins. Full medical glossary
the organ or the body where food is stored and broken down Full medical glossary
Affecting the whole body. Full medical glossary
A group of cells with a similar structure and a specialised function. Full medical glossary
A diagnostic method in which very high frequency sound waves are passed into the body and the reflective echoes analysed to build a picture of the internal organs – or of the foetus in the uterus. Full medical glossary
Expusion of the contents of the stomach through the mouth. Full medical glossary