Gallstones or Gallbladder

The gallbladder is a small pouch under the liver that stores bile, the fluid that helps digest fat. Gallstones are hard pieces that form in that bile, most often made of cholesterol. Most of them cause no trouble at all, but if a stone blocks a duct it can bring on sudden severe pain in the upper abdomen, and less often infection or inflammation of the gallbladder, the bile ducts or the pancreas.

What gallstones are, and what they are not

Having gallstones and having gallbladder disease are not the same thing. Stones are often found by chance on an ultrasound done for another reason, and the Canadian Liver Foundation reports that about 80 per cent of people with gallstones never develop symptoms. Stones like these are usually described as silent, and in Canada they are often simply monitored. Finding stones is not on its own a reason for an operation.

Gallbladder pain is also not ordinary indigestion, although it can be mistaken for it. An attack, sometimes called biliary colic, builds over minutes rather than seconds, sits high in the abdomen or under the breastbone, and lasts from about half an hour to several hours before easing. Pain that comes with fever, or with yellowing of the skin or eyes, points to a complication rather than a simple attack.

Signs and symptoms

• Sudden intense pain in the upper right abdomen or just below the breastbone, often after a fatty meal
• Pain that spreads to the back or to the right shoulder blade
• Pain that builds over minutes and lasts from half an hour to several hours
• Nausea and vomiting during an attack
• Bloating, burping or indigestion between attacks
• Fever and chills, which can point to infection
• Yellowing of the skin or eyes, or dark urine and pale stools, if a bile duct is blocked

Attacks are unpredictable. Some people have one and never another, while others have them in clusters over months. Pain is more likely to follow a meal high in fat, though not always.

What raises the risk

Some risk factors cannot be changed:

• Being female, particularly between the ages of 20 and 60
• Increasing age
• A family history of gallstones
• Previous pregnancies

Others can often be worked on, usually with support from a health care team:

• Carrying extra body weight
• Rapid weight loss, including after weight loss surgery or very low calorie dieting
• Diets low in fibre and high in refined carbohydrates, and low physical activity

How gallstones are diagnosed in Canada

Abdominal ultrasound is the usual first test and is very good at showing stones inside the gallbladder. Blood tests for liver enzymes, bilirubin, lipase and markers of infection help show whether a duct is blocked or the pancreas is involved. If a stone in the bile duct is suspected, hospitals use magnetic resonance cholangiopancreatography, known as MRCP, endoscopic ultrasound, or endoscopic retrograde cholangiopancreatography, known as ERCP, which can also remove a duct stone during the same procedure. A HIDA scan is sometimes used when the question is how well the gallbladder is working. Which test comes next depends on what the ultrasound and the blood work show.

Treatment and day-to-day management

Clinical research for Gallstones or Gallbladder is enrolling. See the current studies ↓

What is offered depends less on whether stones are present than on whether they are causing trouble. Depending on your symptoms, your test results and your other health conditions, a health care team may discuss:

• Watchful waiting for stones found by chance that are not causing symptoms
• Laparoscopic cholecystectomy, keyhole removal of the gallbladder, which is the standard operation in Canada and is often done as day surgery
• Open cholecystectomy where keyhole surgery is not suitable
• Endoscopic procedures such as ERCP to clear stones from the bile duct, sometimes with a stent
• Bile acid medicine, ursodeoxycholic acid, and adjusting dietary fat for selected people who are not having surgery

Waits for planned gallbladder surgery differ a great deal between Canadian hospitals. These are decisions for you, your surgeon and your own clinician, and nothing on this page is a recommendation about any of them.

When to talk to a doctor

• Severe abdominal pain with fever, chills or shaking, which can mean infection of the gallbladder or bile ducts and needs emergency assessment
• Yellowing of the skin or eyes, dark urine or pale stools, which can mean a blocked bile duct
• Pain lasting more than a few hours with repeated vomiting, or unintended weight loss, both of which warrant prompt assessment

Why clinical research matters for gallbladder disease

Two questions remain open. The first is which people with silent stones, or with mild symptoms, actually benefit from an operation. The second is how to reduce the small but real risk of bile duct injury during surgery, and the ongoing symptoms some people have after the gallbladder is removed. Studies are comparing early against delayed surgery for gallbladder inflammation and for pancreatitis, testing imaging and fluorescence techniques that map the ducts during an operation, and looking at non surgical and medicine based approaches for people who cannot have surgery. Researchers are also examining why gallstone rates appear to be rising alongside obesity and metabolic disease.

Clinical studies are how those questions get answered. Taking part is voluntary, you give informed consent before anything begins, and you can stop at any time without affecting the care you get from your own doctor. Joining a study does not mean giving up the care you have now, and no one can say in advance whether a study will help you personally.

Learn more from Canadian sources

• Canadian Liver Foundation: gallstones
• Canadian Digestive Health Foundation: gallbladder removal
• MyHealth.Alberta: laparoscopic gallbladder removal
• HealthLink BC