Gallstones and biliary colic
Gallstones are among the commonest conditions in general surgery, and in Cyprus and the wider Mediterranean they are particularly prevalent. Most people who have them never know. The clinical questions are simple to state and require judgement to answer: is this patient's pain actually from their gallstones, and does this gallbladder need to come out?
How they form
Bile is a solution carrying cholesterol, bile salts and phospholipids in a delicate balance. The gallbladder concentrates it between meals and releases it when fat enters the duodenum. Stones form when that balance fails, and three factors combine:
- Supersaturation — bile contains more cholesterol than the bile salts and phospholipids can keep dissolved, so crystals precipitate.
- Nucleation — crystals aggregate around a nidus, often mucin produced by the gallbladder lining.
- Stasis — impaired gallbladder emptying allows crystals time to grow into stones rather than being flushed out.
Most stones in this population are cholesterol or mixed stones. Pigment stones, composed of calcium bilirubinate, form in different circumstances — chronic haemolysis, where excess bilirubin is produced, and biliary infection or stasis.
The classical risk factors are worth stating because patients ask: increasing age, female sex, pregnancy and parity, oestrogen exposure, obesity, rapid weight loss, diabetes, a family history, and certain ethnic backgrounds. Rapid weight loss deserves emphasis, since it is a common and avoidable precipitant — gallstones frequently appear after crash dieting or bariatric surgery.
Why they cause pain
Understanding the mechanism explains the symptom pattern. Biliary colic occurs when a stone temporarily obstructs the gallbladder outlet — the cystic duct — usually after a meal, when the gallbladder contracts against the obstruction. Pressure rises within the gallbladder and produces pain. When the gallbladder relaxes and the stone falls back, the pain resolves.
This explains why the pain builds over minutes rather than starting abruptly, why it plateaus rather than coming in waves (making "colic" a misnomer), why it lasts thirty minutes to a few hours rather than seconds, and why it settles completely between episodes leaving the patient entirely well. It also explains why a stone that stays impacted causes not colic but cholecystitis — a different illness described on its own page.
Symptoms
- severe, constant pain in the right upper abdomen or epigastrium
- radiation to the back, the right shoulder blade or between the shoulders
- onset often within an hour or two of eating, classically a fatty meal, and frequently at night
- nausea and vomiting
- restlessness — patients characteristically cannot find a comfortable position
- complete resolution between attacks
Symptoms that are not typical of gallstones deserve equal attention: bloating, belching, vague dyspepsia, fatty food intolerance and generalised indigestion are common in the population and are frequently present in people who happen also to have gallstones. Removing the gallbladder does not reliably relieve them. Telling patients this before rather than after surgery is part of honest practice.
How the diagnosis is made
Ultrasound is the investigation of choice — sensitive, inexpensive, without radiation — and it identifies stones, gallbladder wall thickening, and dilatation of the bile duct. It should be performed fasting, as a contracted gallbladder is difficult to assess.
Liver function tests are checked in every case. Abnormal results, particularly a raised bilirubin or alkaline phosphatase, suggest stones may have passed into the bile duct and change the plan.
MRCP or endoscopic ultrasound is used where duct stones are suspected but not confirmed. CT is poor at detecting gallstones, many of which are not radio-opaque, and a normal CT does not exclude them — a point that causes regular confusion when a patient has been scanned for another reason.
Treatment
Asymptomatic gallstones
Stones found incidentally in someone without symptoms do not generally require surgery. The annual risk of developing symptoms is low, and most people never do. Exceptions where prophylactic cholecystectomy is considered include a porcelain (calcified) gallbladder, very large stones, gallbladder polyps meeting criteria for removal, certain haemolytic disorders, and patients undergoing another abdominal operation where removal is straightforward. These are individual decisions rather than automatic ones.
Symptomatic gallstones
Laparoscopic cholecystectomy is the standard treatment, and the reason for offering it is not the pain alone but the risk of complications — acute cholecystitis, duct stones, cholangitis and gallstone pancreatitis — which become progressively more likely once symptoms have begun.
The operation removes the gallbladder through four small incisions. Bile continues to flow from the liver to the intestine; the gallbladder is a reservoir rather than an essential organ, and most people notice no difference in digestion afterwards. A minority experience looser stools for a period, which usually settles.
Conversion to an open operation is occasionally necessary, most often because of dense inflammation obscuring the anatomy. It is a judgement made to avoid injury, not a complication in itself, and patients are counselled about it beforehand. Intraoperative cholangiography or ultrasound is used to clarify anatomy or assess the duct when indicated.
The critical safety principle in this operation is achieving the critical view of safety — unambiguous identification of the cystic duct and cystic artery before anything is divided — because the serious complication of this operation is bile duct injury, and it is largely a failure of identification rather than of technique.
Non-surgical options
Bile acid dissolution therapy and lithotripsy have very limited roles: they work only for small cholesterol stones in a functioning gallbladder, take many months, and stones recur in the majority because the gallbladder that produced them remains. They are reserved for patients genuinely unfit for surgery.
Recovery
Laparoscopic cholecystectomy is frequently a day case or one-night stay. Most people return to office work within one to two weeks and to full activity, including lifting and exercise, by four weeks. Shoulder-tip discomfort from the gas used during laparoscopy is common for a day or two. No special long-term diet is required, though some patients prefer to reintroduce fatty food gradually in the first weeks.
Follow-up
A single postoperative review is usually sufficient. Persistent symptoms after surgery warrant investigation rather than reassurance, since they suggest either a retained duct stone or that the original symptoms were never biliary.
When to seek a surgical opinion
When attacks of characteristic biliary pain have occurred, since the risk of complications rises once symptoms begin. Urgently if pain persists beyond several hours, or is accompanied by fever, jaundice or rigors — these indicate cholecystitis, duct obstruction or cholangitis rather than simple colic. An opinion is equally worthwhile for the patient with gallstones and atypical symptoms, where the more useful answer may be that the gallbladder is not the problem.
Common questions
Can gallstones go away on their own?
No. Once formed, gallstones do not dissolve or pass out of the gallbladder by themselves. Dissolution medication works only for small cholesterol stones, takes many months, and the stones return in most people because the gallbladder that produced them is still there.
Do I have to have my gallbladder removed?
If your gallstones have never caused symptoms, usually not. If you have had attacks of biliary pain, surgery is generally advised — not because of the pain itself, but because once symptoms start, the chance of a more serious complication such as infection of the gallbladder, a stone blocking the bile duct, or pancreatitis rises considerably.
Can I live normally without a gallbladder?
Yes. The gallbladder stores and concentrates bile but does not produce it. After removal, bile flows continuously from the liver to the intestine. Most people notice no difference in digestion. A minority have looser or more frequent stools for a few weeks or months, which usually settles.
What can I eat after gallbladder surgery?
There is no special long-term diet. Most people return to eating normally within a few weeks. It is reasonable to reintroduce very fatty or fried food gradually over the first weeks rather than immediately.
How long does it take to recover from keyhole gallbladder surgery?
Most patients go home the same day or after one night. Office work is usually possible within one to two weeks, and full activity including lifting and exercise by about four weeks. Discomfort at the small incisions, and shoulder-tip discomfort from the gas used during the operation, are normal for the first few days.
Is gallbladder surgery dangerous?
Laparoscopic cholecystectomy is one of the most commonly performed abdominal operations and is generally safe. As with any operation there are risks, the most significant being injury to the bile duct, which is uncommon. These are discussed individually before surgery.
Where is gallbladder pain felt?
Typically in the upper right abdomen or just below the breastbone, often spreading to the back, the right shoulder blade, or between the shoulders. It builds over several minutes, stays constant for thirty minutes to a few hours, and then settles completely.
My bloating and indigestion — is it my gallstones?
Often not. Bloating, belching, wind and general indigestion are very common, and many people who have them also happen to have gallstones without the two being connected. Removing the gallbladder does not reliably relieve these symptoms. This is worth establishing before surgery rather than after.
Can gallstones cause cancer?
Gallbladder cancer is rare, and the great majority of people with gallstones never develop it. Long-standing stones and a calcified (porcelain) gallbladder are associated with an increased risk, which is one reason a porcelain gallbladder is usually removed even without symptoms.
Related conditions
Other conditions of the gallbladder & bile ducts covered on this site:
- Acute cholecystitis
- Common bile duct stones and cholangitis
- Gallbladder polyps
- Obstructive jaundice
- Gallbladder cancer
- Cholangiocarcinoma (bile duct cancer)
- Bile duct strictures, cysts and benign tumours
- Bile duct injury after gallbladder surgery
This page provides general information and does not replace an individual medical consultation. Assessment and treatment are decided for each patient after review of their history, examination and investigations.