Gallstones
Gallstones are hardened deposits that form within the gallbladder, the small organ beneath the liver that stores and releases bile. They are very common and often cause no symptoms, but they are also one of the most frequent reasons for abdominal surgery worldwide. When gallstones cause symptoms, they can produce biliary colic, cholecystitis (inflammation of the gallbladder), pancreatitis, or obstruction of the bile ducts. Imaging—particularly ultrasound, MRI with MR cholangiopancreatography (MRCP), and CT—is central to diagnosis and management.
What is it?
The gallbladder is a small, pear-shaped organ tucked under the right side of the liver. It stores and concentrates bile, a fluid made by the liver that helps digest fats and remove certain waste products. When food—particularly fatty food—enters the small intestine, the gallbladder contracts and releases bile through the cystic duct, which joins the common bile duct on its way to the duodenum. Gallstones are hardened deposits that form within the gallbladder (and, less commonly, within the bile ducts themselves). They can vary widely in size, from tiny “gallbladder sand” or microliths only a few millimeters across to larger stones several centimeters in diameter, and patients can have anywhere from a single stone to many.
Gallstones are classified mainly by their composition. The most common type is cholesterol stones, which form when bile contains too much cholesterol relative to bile salts and other components, causing cholesterol to crystallize. Pigment stones (often black) develop in conditions where there is excess bilirubin, such as hemolytic disorders, cirrhosis, and certain chronic conditions. Brown pigment stones often form in the bile ducts in association with infection and parasitic disease. Mixed stones contain combinations of these components.
Many factors influence the development of gallstones. Female sex, increasing age, pregnancy, hormonal therapy (such as estrogen-containing contraceptives), obesity, rapid weight loss (including after bariatric surgery), diabetes, metabolic syndrome, family history, certain ethnic backgrounds, and prolonged fasting or total parenteral nutrition all increase risk. Cirrhosis, hemolytic disorders, certain medications, ileal disease (such as Crohn disease or surgical removal of the ileum), and—in some regions—parasitic infections also contribute. Sedentary lifestyle and certain dietary patterns may play a role.
Most gallstones cause no symptoms and are discovered incidentally on imaging done for other reasons. These “silent” gallstones do not necessarily require treatment, although in selected patients with certain risk factors, surgery may be considered preventively. When gallstones cause symptoms, the most common pattern is biliary colic—episodes of moderate to severe upper right or central abdominal pain that often begin after fatty meals, last from minutes to several hours, and may radiate to the right shoulder or back. Nausea, vomiting, bloating, and indigestion may accompany the pain. These episodes typically resolve once the stone moves back into the gallbladder or passes.
Complications can be more serious. Acute cholecystitis occurs when a stone obstructs the cystic duct and the gallbladder becomes inflamed, often with persistent pain, fever, and tenderness in the upper right abdomen. Choledocholithiasis—stones that pass into the common bile duct—can cause biliary obstruction, jaundice, and acute cholangitis (a serious infection of the bile ducts with fever, chills, abdominal pain, and jaundice). Gallstone pancreatitis develops when a stone obstructs the pancreatic duct or the ampulla, triggering pancreatic inflammation that can range from mild to severe. Less commonly, gallstones can erode through the wall of the gallbladder or bile duct into nearby organs, causing complications such as gallstone ileus. Long-standing gallbladder disease is also associated with a small increased risk of gallbladder cancer in certain settings.
Diagnosis combines clinical assessment with imaging and laboratory tests. Blood tests are often normal between attacks but may show abnormalities suggesting complications, such as elevated liver enzymes, bilirubin, alkaline phosphatase, and pancreatic enzymes (amylase and lipase) when complications occur. Ultrasound of the abdomen is the primary imaging test for gallstones because it is widely available, accurate for stones in the gallbladder, and uses no radiation. MRI with MR cholangiopancreatography (MRCP) is particularly valuable for evaluating the bile ducts and detecting common bile duct stones when ultrasound is inconclusive. CT can be useful in certain situations, particularly for evaluating complications, although it is less sensitive than ultrasound for small gallbladder stones. Endoscopic ultrasound provides high-resolution imaging of the gallbladder and bile ducts and is used in select cases. Endoscopic retrograde cholangiopancreatography (ERCP) is generally used for treatment of bile duct stones rather than as a first diagnostic test.
Important to Know
Management of gallstones is highly individualized and depends on whether the stones are causing symptoms, whether complications have developed, and the patient’s overall health. For most patients with asymptomatic gallstones, no specific treatment is needed beyond reassurance, and surgery is not routinely recommended. Lifestyle measures—including a healthy diet, regular physical activity, weight management, avoiding rapid weight loss, and treatment of metabolic conditions—support overall health and may reduce the risk of future symptoms.
For patients with symptomatic gallstones, laparoscopic cholecystectomy (gallbladder removal through small incisions) is the standard treatment and is one of the most commonly performed elective abdominal surgeries. It generally provides definitive resolution of symptoms with relatively short recovery time. Open surgical removal is reserved for more complex situations. Most people live well without a gallbladder, with bile flowing directly from the liver into the small intestine; mild changes in stool consistency or tolerance for fatty foods sometimes occur and are usually well tolerated.
Acute complications often require urgent treatment. Acute cholecystitis is typically managed with hospitalization, antibiotics, and—in many cases—early laparoscopic cholecystectomy during the same admission. Patients who are too unwell or have other reasons surgery cannot be performed immediately may benefit from percutaneous cholecystostomy (a catheter placed through the skin into the gallbladder) as a temporizing measure. Common bile duct stones are usually removed endoscopically through ERCP, often before or shortly after cholecystectomy. Cholangitis is a medical emergency that requires intravenous antibiotics, supportive care, and urgent biliary drainage. Gallstone pancreatitis is managed with supportive care, with bile duct stone removal in selected patients and cholecystectomy generally performed during the same admission once the patient stabilizes.
Medical therapy with bile acid medications such as ursodeoxycholic acid is used in selected situations—for example, in certain types of cholesterol stones in patients who are not surgical candidates, in some patients undergoing rapid weight loss, or in specific syndromic conditions. These medications are not effective for all stones and generally work slowly.
Patients with conditions that increase the risk of complications—such as porcelain gallbladder, very large gallstones in certain populations, gallbladder polyps with high-risk features, hereditary spherocytosis, sickle cell disease, and certain other situations—may be considered for cholecystectomy even without typical symptoms.
Care is typically coordinated by primary care clinicians, general surgeons (often with hepatobiliary expertise), gastroenterologists, and—when relevant—interventional radiologists and hepatologists. Imaging and laboratory findings are interpreted alongside the patient’s symptoms, examination, and broader clinical context rather than in isolation. Patients with gallstones benefit from understanding when to seek care, recognizing warning signs, and—after cholecystectomy—general dietary guidance during recovery.
Red flag symptoms include severe persistent upper right or central abdominal pain, high fever with chills, persistent vomiting, jaundice or dark urine and pale stools, signs of severe infection or shock, severe upper abdominal pain radiating to the back (which may suggest pancreatitis), confusion, or signs of gastrointestinal bleeding. These warrant prompt or urgent medical evaluation, as they may indicate cholecystitis, cholangitis, pancreatitis, or other serious complications of gallstone disease.