24th July 2023

Gallstones

Also referred to as cholelithiasis, gallstones are a very common pathology. They consist of concentrated deposits of bile – with cholesterol being the main component – and can cause a spectrum of disease. Many people have gallstones incidentally, which remain present in the gallbladder without causing any symptoms. If gallstones migrate, they can cause obstruction of the biliary tree, and thus become symptomatic.

Causes and risk factors

Gallstones are associated with various demographic and lifestyle risk factors. Middle age, female sex and pregnancy, obesity, and family history are among the most important. A medical maxim for patients most at risk of gallstones is the ‘four Fs’ – “fat, female, fertile and forty”.

Clinical features

As mentioned, most people who have gallstones are asymptomatic. Migration of gallstones into the ducts leads to ‘attacks’ known as biliary colic. These present with acute abdominal pain, generally in the right upper quadrant or epigastrium, which may be associated with nausea and vomiting, lasting for several hours at a time. Pain may be referred to the right shoulder. Attacks are typically after eating meals; the gallbladder contracts as part of the digestive process, leading to stones becoming dislodged.

If biliary obstruction occurs as a result of gallstones, then patients may also present with jaundice and pruritus, and a cholestatic picture (elevated ALP/GGT) on LFTs.

Gallstones can also lead to acute cholecystitis and cholangitis (see below).

Assessment and diagnosis

Ultrasound scan is the diagnostic investigation of choice, which will demonstrate the presence of gallstones in the biliary tree, and can also be used to demonstrate duct obstruction and dilation.

Management

Management depends on the extent of disease and whether the patient is symptomatic.

Most people with asymptomatic gallstones are managed conservatively – lifestyle advice is the first line measure, such as weight loss and a low-fat diet.

If gallstones are symptomatic, then cholecystectomy should be offered – this can be done electively in most cases but may need to be done as emergency management if a patient has acute severe pain or presents with complications.