Gallstones
Exam Tips
- Typical biliary colic is steady RUQ/epigastric pain lasting >30 minutes and <8 hours, often with nausea but usually no fever.
- Fever + RUQ tenderness (Murphy positive) points to acute cholecystitis; fever + jaundice + RUQ pain (Charcot triad) is cholangitis until proven otherwise.
- Normal ultrasound does not fully exclude stones; if suspicion for CBD stones persists with abnormal LFTs or duct dilatation, think MRCP/EUS.
- Most incidental asymptomatic stones are managed expectantly; operating decisions are driven by symptoms/complications.
- See Figure from core surgery text/teaching atlas showing ultrasound acoustic shadowing and biliary tree anatomy for viva-style image interpretation.
Definition
Gallstones (cholelithiasis) are solid concretions that form in bile, usually within the gallbladder, and are most commonly cholesterol stones in UK and other developed populations. Gallstone disease includes stones in the gallbladder and biliary tree (for example choledocholithiasis) plus the symptoms and complications they can cause; however, most people remain asymptomatic for years.
Pathophysiology
Stone formation reflects disordered bile chemistry and gallbladder kinetics. Cholesterol stones typically arise from cholesterol supersaturation of bile, accelerated crystal nucleation, and reduced gallbladder emptying; pigment stones are linked to excess bilirubin/calcium salts (for example with haemolysis, cirrhosis, infection, or biliary stasis). Symptoms occur when transient or persistent obstruction develops at the cystic duct, common bile duct, or ampulla, producing biliary colic, cholecystitis, obstructive jaundice, cholangitis, or gallstone pancreatitis. See Figure from hepatobiliary anatomy/ultrasound teaching pages showing gallbladder neck or CBD obstruction and downstream effects.
Risk Factors
- Female sex (about 2-3 times higher incidence than men)
- Increasing age (notably >40 years, highest in older age groups)
- Obesity (BMI >30)
- Rapid weight loss or prolonged fasting (including post-bariatric surgery, especially >1.5 kg/week loss)
- Type 2 diabetes mellitus
- Crohn's disease or terminal ileal disease
- Cirrhosis, cystic fibrosis, and haemolytic anaemias (especially black pigment stones)
- Non-alcoholic fatty liver disease
- Diet high in refined carbohydrate/triglyceride and low in fibre
- Medications: octreotide, GLP-1 receptor agonists, ceftriaxone
- Hormone replacement therapy
- Genetic/family and ethnic susceptibility
Clinical Features
Symptoms
- Biliary colic: steady severe right upper quadrant or epigastric pain lasting >30 minutes (typically <8 hours)
- Pain may follow meals and can radiate to back/right scapula
- Nausea and vomiting
- Fever/rigors suggest infective complication (acute cholecystitis or cholangitis)
- Jaundice symptoms: dark urine and pale stools in biliary obstruction
- Gallstone pancreatitis pattern: constant epigastric pain radiating to the back with profuse vomiting
Signs
- Right upper quadrant tenderness
- Murphy's sign positivity in acute cholecystitis
- Pyrexia and tachycardia in inflammatory/infective disease
- Jaundice in choledocholithiasis/cholangitis
- Charcot triad (RUQ pain + fever + jaundice) indicates acute cholangitis
- Hypotension/confusion indicates severe sepsis and urgent escalation
Investigations
Management
Lifestyle Modifications
- No treatment for incidentally found asymptomatic gallstones unless specific high-risk indications
- Weight management with gradual reduction (avoid crash dieting) and balanced high-fibre diet
- Hydration and avoidance of prolonged fasting
- Safety-net urgently for fever, jaundice, persistent pain >6 hours, hypotension, or confusion
Pharmacological Treatment
Analgesia and antiemetic (symptomatic episodes)
- Paracetamol 1 g orally every 4-6 hours (max 4 g/day)
- Ibuprofen 400 mg orally three times daily with food (max 2.4 g/day prescribed)
- Morphine sulfate 5-10 mg IV, titrated in severe pain
- Cyclizine 50 mg oral/IM/IV up to three times daily
Avoid NSAIDs in significant renal impairment, active peptic ulcer disease, severe heart failure, or NSAID hypersensitivity. Use opioid sparingly and monitor sedation/respiratory depression.
Antibiotics (only when infection suspected: acute cholecystitis/cholangitis)
- Co-amoxiclav 1.2 g IV every 8 hours
- Piperacillin/tazobactam 4.5 g IV every 8 hours in severe sepsis
- If penicillin allergy: ciprofloxacin 400 mg IV every 12 hours plus metronidazole 500 mg IV every 8 hours
Start promptly in sepsis, then tailor to cultures/local policy. Check allergy status, renal dosing, C. difficile risk, and QT risk (fluoroquinolones).
Bile acid therapy (selected non-surgical candidates only)
- Ursodeoxycholic acid 8-10 mg/kg/day orally in divided doses
Limited role: only for small radiolucent cholesterol stones with a functioning gallbladder; recurrence after stopping is common. Avoid in complete biliary obstruction and non-functioning/calcified gallbladder.
Surgical / Interventional
- Elective laparoscopic cholecystectomy for symptomatic biliary colic to prevent recurrence/complications
- Early laparoscopic cholecystectomy for acute cholecystitis (ideally during index admission)
- ERCP with sphincterotomy and stone extraction for choledocholithiasis/cholangitis, followed by cholecystectomy when fit
- Urgent biliary decompression (usually ERCP) in severe acute cholangitis with sepsis
Complications
- Recurrent biliary colic
- Acute cholecystitis (with risk of empyema, gangrene, perforation, fistula)
- Choledocholithiasis with obstructive jaundice
- Acute cholangitis (life-threatening biliary sepsis)
- Gallstone pancreatitis
- Mirizzi syndrome
- Gallstone ileus or Bouveret syndrome
- Biliary peritonitis
- Association with gallbladder carcinoma
Prognosis
Around 80% of people with gallstones remain asymptomatic. Roughly 2-4% of previously asymptomatic patients develop symptoms each year, and once symptomatic, recurrence risk is high, so definitive treatment is often required. Outcome is generally good with timely treatment, but delayed recognition of cholangitis or severe pancreatitis carries substantial mortality.
Sources & References
💊BNF Drug References(2)
- Codeine phosphate[cautions]
- Ursodeoxycholic acid[management.pharmacological]
✅NICE Guidelines(1)
- Gallstones[overview]