Gallstones (Cholelithiasis)

Why do Gallstones develop?

These stones form when the substances that make up bile fall out of balance, causing particles to crystallise and harden inside the gallbladder. Although they may start as tiny grains, they can gradually grow into larger stones or multiple small stones that interfere with normal bile flow. 

Some of the factors that stimulate gallstone formation are:

What are the symptoms of Gallstones?

It should be noted that gallstones can remain silent for years. This is because symptoms tend to appear once a stone blocks the flow of bile. While these symptoms are kept brief here, each can vary significantly between individuals.

Generally, symptoms include:

• Upper right abdominal pain, often after a heavy or oily meal
• Pain that radiates to the back or right shoulder
• Nausea or vomiting
• Indigestion or bloating
• Sudden episodes of severe abdominal discomfort (biliary colic symptoms)

Who is at risk of developing Gallstones?

Certain groups of people are more prone to developing gallstones because of how their bile is produced, how their gallbladder contracts or how their body processes cholesterol and bilirubin. While anyone can develop gallstones, some factors increase the likelihood more than others, such as:

Biological and genetic factors

• Age – the risk rises after the age of 40 years old due to changes in metabolism and gallbladder motility make cholesterol more likely to crystallise.
• Gender – women experience higher rates of gallstones due to oestrogen and progesterone, which influence both bile composition and gallbladder emptying.
• Family history – gallstones often run in families. These inherited traits influence how cholesterol is processed and how efficiently the gallbladder contracts. 
• Ethnicity – certain ethnic groups naturally produce bile with higher cholesterol concentrations or have slower gallbladder motility, increasing the likelihood of stone formation.

Hormonal factors

• Hormonal fluctuations – pregnancy, oral contraceptives and hormone replacement therapy can all alter bile chemistry. Higher oestrogen increases cholesterol saturation, while progesterone can slow gallbladder emptying, creating conditions that favour gallstone formation.

Health-related factors

• Chronic haemolytic disorders – conditions that break down red blood cells and produce excess bilirubin, leading to the development of pigment stones.
• Diabetes – high triglycerides and altered gallbladder motility associated with diabetes can increase cholesterol stone formation.
• Liver disease – liver conditions can reduce the production of bile salts, which are needed to keep cholesterol dissolved, raising the risk of stone formation.
• High blood LDL levels – elevated LDL levels influence how cholesterol is processed by the body and make bile more prone to crystallisation.

Lifestyle factors

• Low-fibre, high-fat diet – eating patterns rich in fats and low in fibre affect bile composition and slow digestion, allowing cholesterol crystals to form more easily.
• Sedentary lifestyle – inactivity affects overall metabolism and cholesterol handling, indirectly contributing to gallstone risk.
• Overweight or obese – excess body fat increases cholesterol production in the liver, which raises the cholesterol concentration in bile and promotes crystallisation.
• Rapid weight loss – strict dieting and fasting trigger the liver to release more cholesterol into bile, while reduced eating slows gallbladder contractions, making stone formation more likely.

What happens if Gallstones are left untreated?

Gallstones do not always cause problems, but when they block ducts or trigger inflammation, they can lead to several painful and potentially serious complications. This includes, but is not limited to:

• Acute Cholecystitis (Gallbladder Inflammation) – when a gallstone becomes lodged in the cystic duct, bile cannot drain properly, causing the gallbladder to swell and become inflamed. Without treatment, inflammation can progress to infection or even tissue death (gangrene) of the gallbladder.
• Choledocholithiasis (Stones in the Common Bile Duct) – stones that slip into and obstruct the common bile duct prevent bile from reaching the intestine. If the blockage is not cleared, it may set the stage for more serious infections.
• Cholangitis (Infection of the Bile Ducts) – a blocked bile duct can quickly become infected when bacteria enter the stagnant bile. Cholangitis is a medical emergency, often requiring prompt treatment to prevent the infection from spreading into the bloodstream.
• Gallstone Pancreatitis – if a stone blocks the pancreatic duct or the shared opening with the bile duct, digestive enzymes may become trapped inside the pancreas. This can trigger pancreatitis, a painful inflammatory condition that often requires hospitalisation. 
• Gallbladder Empyema (Pus in the Gallbladder) – in advanced or untreated cholecystitis, the gallbladder can fill with pus, leading to severe infection. This complication carries a higher risk of sepsis and generally requires urgent surgical intervention.
• Gallbladder Perforation – if inflammation or infection is left unaddressed, the gallbladder wall may weaken and eventually rupture. A perforation causes bile to leak into the abdominal cavity, leading to widespread infection (peritonitis) and requiring emergency surgery.
• Gallstone Ileus – occasionally, a large gallstone can erode through the gallbladder wall into the intestine. Once inside the bowel, the stone may cause an intestinal blockage, often requiring surgical removal.

Oral medication

• Painkillers – gallstone attacks can be intensely painful. Short-term pain relief, such as non-steroidal anti-inflammatory drugs (NSAIDs), helps patients remain comfortable while further tests or procedures are arranged.
• Antibiotics – when inflammation or infection of the gallbladder or bile ducts is present, antibiotics are started promptly to prevent the condition from worsening. This is often used in cases of acute cholecystitis or cholangitis.
• Bile acid medications – drugs such as ursodeoxycholic acid (UDCA) or chenodeoxycholic acid (CDCA) work by reducing cholesterol saturation in bile, gradually dissolving small cholesterol stones over time.

Surgical treatment

Gallstone removal

Laparoscopic Cholecystectomy is the established benchmark for symptomatic gallstones. This minimally invasive procedure offers long-term relief because gallstones cannot recur once the gallbladder is removed.

Minimally invasive treatment is recommended when:

• Repeated gallstone attacks occur
• The gallbladder is inflamed or infected
• Gallstones have caused complications
• There is a high risk of future episodes

Most patients return home the same day or after one night, with a quick recovery and minimal scarring. Digestion remains normal because bile flows directly from the liver to the intestine.

Bile duct stone removal

If stones have migrated into the common bile duct, a different approach is needed.

Endoscopic Retrograde Cholangiopancreatography allows doctors to:

• Locate ductal stones
• Remove them during the same procedure
• Insert stents if swelling or blockage persists

ERCP is often performed urgently when patients develop jaundice, fever or pancreatitis. After ductal stones are cleared, gallbladder removal is usually advised to prevent recurrence.

Lifestyle and dietary modifications

• Balanced, low-fat diet – eating lighter meals with less saturated fat helps prevent gallbladder overload and reduces the risk of triggering gallstone attacks.
• Regular meal schedule – avoiding skipped meals keeps bile moving and prevents it from becoming stagnant and concentrated.
• Hydration – drinking enough water supports healthy bile flow and overall digestive function.
• Gradual weight management – slow, steady weight loss is preferred over rapid dieting, which can increase gallstone formation.
• Exercise and cholesterol control – regular physical activity and maintaining healthy cholesterol levels contribute to long-term gallbladder health.

Emergency Gallstone removal surgery

Emergency gallstone surgery is considered when a stone causes sudden blockage or severe inflammation within the gallbladder or bile ducts. In these situations, the priority is to stabilise the patient, relieve obstruction and prevent complications such as infection or pancreatitis. The type of surgery recommended depends on the clinical findings, severity of symptoms and imaging results.

When is emergency surgery required?

Emergency gallbladder surgery may be advised when any of the following are present:

• Acute cholecystitis — inflammation and swelling of the gallbladder due to a blocked cystic duct.
  
  
• Cholangitis — infection of the bile ducts, often accompanied by fever, jaundice and abdominal pain.
  
  
• Gallstone pancreatitis — when a stone blocks the pancreatic duct or its shared opening with the bile duct, causing inflammation of the pancreas.
  
  
• Persistent bile duct obstruction — when a stone remains lodged in the common bile duct despite initial management.
  
  
• Signs of sepsis or worsening infection — indicating that prompt intervention is required.

The most common procedure performed in urgent situations is laparoscopic cholecystectomy, where the gallbladder is removed through small incisions. This approach is typically preferred because removing the gallbladder prevents recurrent attacks once the acute condition is managed.

If a stone is lodged in the common bile duct, an Endoscopic Retrograde Cholangiopancreatography (ERCP) may be performed before or after surgery to remove the obstruction and restore bile flow.