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.

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
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 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
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
Inflammation of the bladder. Full medical glossary
Water deficiency in the body. Full medical glossary
An abbreviation for endoscopic retrograde cholangiopancreaticogram. 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 body’s response to injury. Full medical glossary
A type of minimally invasive surgery. Full medical glossary
A keyhole surgical procedure. 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
Affecting the whole body. Full medical glossary