Gallstones (Cholelithiasis)
Summary
Gallstones (cholelithiasis) are solid deposits in the gallbladder, composed of cholesterol (80%) or bile pigments (20%). They are extremely common, affecting 10-15% of Western populations, but most (80%) remain asymptomatic. Symptomatic gallstones present with biliary colic — colicky RUQ pain after fatty meals, often radiating to the right scapula (Boas sign). Complications include acute cholecystitis, choledocholithiasis (CBD stones), cholangitis, and gallstone pancreatitis. Diagnosis is by ultrasound. Symptomatic gallstones are treated with laparoscopic cholecystectomy. Asymptomatic gallstones generally require no treatment.
Key Facts
- Prevalence: 10-15% of adults; Increases with age
- Composition: 80% Cholesterol; 20% Pigment (bilirubin)
- Risk factors (5 Fs): Fat, Female, Forty, Fertile, Fair
- Symptoms: RUQ pain, radiates to scapula, post-fatty meal
- Diagnosis: Ultrasound (95% sensitivity for gallbladder stones)
- Treatment: Laparoscopic cholecystectomy for symptomatic stones
- Asymptomatic: Usually watched (no treatment)
Clinical Pearls
"5 Fs = Fat, Female, Forty, Fertile, Fair": The classic risk factor mnemonic. Also add Family history and Fasting (rapid weight loss).
"Biliary Colic = No Fever, No Jaundice": Simple gallstones cause pain but not inflammation. If fever or jaundice, think cholecystitis or CBD stones.
"Murphy's Sign = Cholecystitis": Arrest of inspiration during palpation of RUQ indicates inflammation (cholecystitis), not simple colic.
"USS First, MRCP/ERCP for CBD": Ultrasound diagnoses gallbladder stones. MRCP or ERCP is needed if CBD stones suspected (jaundice, dilated CBD).
Why This Matters Clinically
Gallstones are common and their complications can be life-threatening. Recognising when to operate (symptomatic stones) and when to escalate (cholecystitis, cholangitis) is essential.[1,2]
Incidence & Prevalence
| Parameter | Data |
|---|---|
| Prevalence | 10-15% of Western adults |
| Symptomatic | Only 20% of stones become symptomatic |
| Sex | Female:Male = 2:1 |
| Age | Increases with age |
Risk Factors (5 Fs + More)
| Factor | Notes |
|---|---|
| Fat | Obesity; BMI >30 |
| Female | Oestrogen increases cholesterol secretion |
| Forty | Age >40 |
| Fertile | Pregnancy; Multiparity |
| Fair | Caucasian; Also Native American |
| Family history | Genetic component |
| Fasting/Rapid weight loss | Bile stasis |
Stone Formation
| Type | Composition | Risk Factors |
|---|---|---|
| Cholesterol stones | 80%; Yellow-green | 5 Fs; Obesity; Western diet |
| Pigment stones (Black) | Bilirubin polymer | Haemolysis; Cirrhosis |
| Pigment stones (Brown) | Infection-related | Biliary infection; Asian populations |
Mechanism
| Step | Details |
|---|---|
| 1 | Supersaturation of bile with cholesterol |
| 2 | Nucleation — cholesterol crystals form |
| 3 | Gallbladder dysmotility — hypomotility, stasis |
| 4 | Stone growth |
Complications Pathway
| Complication | Mechanism |
|---|---|
| Biliary colic | Stone transiently impacts cystic duct |
| Acute cholecystitis | Stone persistently obstructs cystic duct → Inflammation |
| Choledocholithiasis | Stone migrates to CBD |
| Cholangitis | CBD obstruction + infection |
| Gallstone pancreatitis | Stone impacts ampulla → Pancreatic duct obstruction |
| Mirizzi syndrome | Stone in Hartmann's pouch compresses CBD |
| Gallstone ileus | Stone erodes into duodenum → SBO at terminal ileum |
Biliary Colic
| Feature | Notes |
|---|---|
| Pain | RUQ/Epigastric; Colicky then constant |
| Timing | After fatty meals |
| Radiation | Right scapula (Boas sign); Back |
| Duration | 30 mins - 6 hours |
| No fever | If fever → Cholecystitis |
| No jaundice | If jaundice → CBD stones |
Red Flags
[!CAUTION]
- Fever (cholecystitis)
- Jaundice (CBD stones)
- Charcot's triad: Fever + Jaundice + RUQ pain (cholangitis)
- Reynold's pentad (add confusion + hypotension = severe cholangitis)
- Vomiting with abdominal distension (gallstone ileus)
Abdominal Examination
| Finding | Notes |
|---|---|
| RUQ tenderness | Common |
| Murphy's sign | Positive in cholecystitis |
| Jaundice | CBD obstruction |
| Palpable gallbladder | Rare; Suggests mucocoele or empyema |
Murphy's Sign
- Examiner's hand under right costal margin
- Patient takes deep breath
- Positive = Arrest of inspiration due to pain as inflamed gallbladder descends
First-Line
| Investigation | Purpose |
|---|---|
| Abdominal USS | Gold standard; 95% sensitivity for gallbladder stones |
| Blood tests | FBC, LFTs, Amylase |
Second-Line (CBD Stones Suspected)
| Investigation | Purpose |
|---|---|
| MRCP | Non-invasive CBD imaging |
| ERCP | Therapeutic (sphincterotomy + stone extraction) |
| EUS | Endoscopic ultrasound if MRCP equivocal |
Ultrasound Findings
| Finding | Significance |
|---|---|
| Stones | Echogenic foci with acoustic shadowing |
| Dilated CBD | >6 mm (or >8 mm post-cholecystectomy) |
| Thickened gallbladder wall | >4 mm = Cholecystitis |
| Pericholecystic fluid | Cholecystitis |
Management Algorithm
GALLSTONES MANAGEMENT
↓
┌───────────────────────────────────────────────────────────┐
│ ASYMPTOMATIC GALLSTONES │
├───────────────────────────────────────────────────────────┤
│ ➤ Usually NO treatment required │
│ ➤ Incidental finding on imaging │
│ ➤ Advise to seek help if symptoms develop │
│ │
│ EXCEPTIONS (Consider prophylactic cholecystectomy): │
│ ➤ Porcelain gallbladder (cancer risk) │
│ ➤ Gallbladder polyps >10 mm │
│ ➤ Patient immunosuppressed │
└───────────────────────────────────────────────────────────┘
↓
┌───────────────────────────────────────────────────────────┐
│ SYMPTOMATIC GALLSTONES (Biliary Colic) │
├───────────────────────────────────────────────────────────┤
│ ➤ Analgesia: NSAIDs (e.g., Diclofenac 75 mg IM/PR) │
│ ➤ Low-fat diet advice │
│ ➤ Elective laparoscopic cholecystectomy │
│ • Definitive treatment │
│ • Day-case surgery │
│ • Very low complication rate │
└───────────────────────────────────────────────────────────┘
↓
┌───────────────────────────────────────────────────────────┐
│ ACUTE CHOLECYSTITIS │
├───────────────────────────────────────────────────────────┤
│ ➤ Admit │
│ ➤ NBM; IV fluids │
│ ➤ IV antibiotics (e.g., Co-amoxiclav) │
│ ➤ Cholecystectomy within 72 hours (hot cholecystectomy) │
│ OR │
│ ➤ Interval cholecystectomy at 6-8 weeks if delayed │
│ │
│ ⚠️ If unfit for surgery: Percutaneous cholecystostomy │
└───────────────────────────────────────────────────────────┘
↓
┌───────────────────────────────────────────────────────────┐
│ CBD STONES (Choledocholithiasis) │
├───────────────────────────────────────────────────────────┤
│ ➤ MRCP to confirm │
│ ➤ ERCP + Sphincterotomy + Stone extraction │
│ ➤ Followed by laparoscopic cholecystectomy │
│ │
│ ⚠️ If cholangitis: Urgent ERCP within 24-48 hours │
└───────────────────────────────────────────────────────────┘
| Complication | Notes |
|---|---|
| Acute cholecystitis | Persistent cystic duct obstruction + inflammation |
| Choledocholithiasis | CBD stones; Jaundice; Dilated CBD |
| Cholangitis | CBD obstruction + infection; Emergency |
| Gallstone pancreatitis | Stone impacts ampulla |
| Mirizzi syndrome | Stone compresses CBD extrinsically |
| Gallstone ileus | SBO at terminal ileum; Air in biliary tree (pneumobilia) |
| Gallbladder carcinoma | Rare; Associated with chronic inflammation |
| Factor | Outcome |
|---|---|
| Cholecystectomy | Curative; Excellent outcomes |
| Recurrent symptoms | 10-15% post-cholecystectomy syndrome |
| Asymptomatic stones | 2-3%/year become symptomatic |
Key Guidelines
| Guideline | Organisation | Year | Key Points |
|---|---|---|---|
| Gallstone Disease | NICE CG188 | 2014 | Investigation and management |
What are gallstones?
Gallstones are solid lumps that form in your gallbladder (a small organ under your liver). They're made mainly from cholesterol.
What are the symptoms?
Many people have no symptoms. If gallstones cause problems, you may get:
- Pain in the upper right side of your tummy (especially after fatty food)
- Feeling sick
How are they treated?
- No symptoms: Usually no treatment needed
- Symptoms: Keyhole surgery to remove the gallbladder (cholecystectomy)
- You can live normally without a gallbladder
When should I seek help?
See a doctor urgently if you have:
- Severe pain that doesn't go away
- Fever
- Yellow skin or eyes
- NICE. Gallstone disease (CG188). 2014. nice.org.uk/guidance/cg188
High-Yield Exam Topics
| Topic | Key Points |
|---|---|
| 5 Fs | Fat, Female, Forty, Fertile, Fair |
| Biliary colic | RUQ pain post-fatty meal; No fever/jaundice |
| Murphy's sign | Positive in cholecystitis |
| USS | First-line; Acoustic shadowing |
| Treatment | Lap chole for symptomatic; Watch asymptomatic |
| Charcot's triad | Fever + Jaundice + RUQ pain = Cholangitis |
Sample Viva Question
Q: A 45-year-old presents with RUQ pain after a fatty meal. How would you investigate and manage?
Model Answer: This is likely biliary colic from gallstones. I would confirm with abdominal ultrasound (gold standard; shows echogenic stones with acoustic shadowing). Bloods: FBC, LFTs, Amylase. If no fever/jaundice, this is uncomplicated biliary colic.
Management: Analgesia (NSAID — diclofenac IM/PR). Advise low-fat diet. Refer for elective laparoscopic cholecystectomy (definitive treatment). If there is fever or Murphy's sign, admit for IV antibiotics and consider hot cholecystectomy within 72 hours for acute cholecystitis. If jaundice, arrange MRCP to assess for CBD stones.
Last Reviewed: 2025-12-24 | MedVellum Editorial Team