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Overview

The gallbladder is a small organ located on the underside of the liver. It stores the bile produced in the liver and releases it into the small intestine, especially after meals containing fat. Bile is a natural fluid that helps digest fats.

When the balance of substances in bile such as cholesterol, bile salts and bilirubin is disturbed, stones can form in the gallbladder. In medical terms, the presence of stones in the gallbladder is called “cholelithiasis”.

Gallbladder stones are very common in the population. In many people they can stay silent for years without causing any symptoms. In others, they can cause attacks of pain, inflammation of the gallbladder, blockage of the bile duct or inflammation of the pancreas.

What you should know

The most important point in the treatment decision is not simply that a stone is seen on ultrasound, but whether it causes typical symptoms or a stone-related complication in the patient [1,2].

Symptoms and Causes

What symptoms can gallbladder stones cause?

Most gallbladder stones cause no symptoms. When symptoms do appear, the most common complaint is “gallstone pain”, known in medical terms as “biliary colic”.

The typical features of gallstone pain are:

It is felt in the upper right part of the abdomen or in the stomach area
It usually lasts longer than 30 minutes
It can continue for up to several hours
It can spread to the right shoulder, the back or below the right shoulder blade
It can be accompanied by nausea and vomiting
In some people it starts particularly after a fatty or heavy meal
It can wake you from sleep at night

Although its name contains the word “colic”, the pain is usually not short cramps that come and go, but a strong pain that gradually builds and then stays constant for a while.

Typical gallstone pain usually does not clearly ease with passing wind, going to the toilet or changing position.

Are bloating and indigestion caused by gallstones?

Bloating, belching, heartburn and indigestion can occur in people with gallstones. However, these complaints are not specific to gallstones. Reflux, gastritis, ulcers, bowel diseases and eating habits can also cause similar complaints.

For this reason, having only indigestion or bloating does not mean that the complaints will definitely go away after gallbladder surgery. Before a decision on surgery is made, it should be assessed whether the complaint is truly consistent with gallstones.

Which symptoms may indicate a more serious problem?

Emergency: 112

The following symptoms may be warning signs of important conditions such as inflammation of the gallbladder, blockage of the bile duct, bile duct infection or inflammation of the pancreas:

Abdominal pain that does not go away within a few hours or keeps getting worse
Fever and shivering
Yellowing of the eyes or skin
Darkening of the urine
Marked lightening of the stool colour
Repeated or persistent vomiting
Marked tenderness in the abdomen
Weakness, low blood pressure or confusion

If any of these symptoms are present, you should go to a healthcare facility without waiting. In particular, pain accompanied by both fever and jaundice requires urgent assessment for bile duct infection.

Why do gallstones form?

Most gallstones are cholesterol stones. In fewer patients, pigment stones made mainly of bilirubin are found.

The main factors that can make stone formation more likely are:

Increasing age
Female sex and hormonal effects
Pregnancy
A family history of gallstones
Excess weight and obesity
Losing weight very quickly
Rapid weight loss after obesity surgery
Prolonged fasting or intravenous feeding
Diabetes and metabolic diseases
Certain liver and bowel diseases
Certain blood diseases in which red blood cells break down rapidly
Use of certain medicines

Having one of these risks does not mean that a person will definitely develop stones. Gallstones usually develop through a combination of more than one factor.

How Is It Diagnosed?

The diagnosis is made by assessing the patient’s symptoms, examination findings, blood tests and imaging results.

What is the first-choice investigation?

The first-choice imaging method for investigating gallbladder stones is abdominal ultrasonography.

Ultrasound:

Does not involve radiation.
Is painless.
Can show gallbladder stones in the large majority of cases.
Can assess whether there is thickening of the gallbladder wall or fluid around it.
Can give information on whether the bile ducts are widened.

The ultrasound result needs to be assessed together with the patient’s complaints and examination findings. Seeing a stone on ultrasound does not mean that all of a person’s abdominal complaints are necessarily caused by the stone.

Which blood tests may be done?

In patients with pain, fever or jaundice, the following tests may be requested:

Full blood count
Markers of infection and inflammation
Bilirubin
Liver enzymes
Bile duct enzymes
Pancreatic enzymes
Kidney function and electrolytes

Normal blood results do not mean that there are no stones in the gallbladder. However, raised values can increase the suspicion of gallbladder inflammation, a bile duct stone or pancreatitis.

When are MR cholangiography (MRCP) and endoscopic ultrasound used?

If ultrasound shows a stone in the common bile duct, the bile duct is widened, jaundice develops or liver tests are raised, it may be necessary to look for a stone in the common bile duct.

For this purpose:

MR cholangiography (MRCP): A special MRI scan that shows the bile ducts in detail without using radiation.
Endoscopic ultrasound (EUS): A close examination of the bile ducts with an ultrasound device at the tip of an endoscope passed through the mouth.

If the likelihood of a stone in the common bile duct is intermediate, confirming the stone first with MRCP or EUS may be preferred rather than performing ERCP straight away. In this way, unnecessary interventional procedures can be avoided [1,3].

What is ERCP?

ERCP is a procedure in which a special endoscope passed through the mouth reaches the duodenum so that the bile duct can be treated. It may be possible to remove a stone from the bile duct, open the duct or, if necessary, place a stent.

Today ERCP is not an investigation used routinely just to make a diagnosis. It is mainly performed for treatment when the likelihood of a stone or blockage in the bile duct is high.

Although ERCP is an effective procedure, it can lead to complications such as pancreatitis, bleeding, infection and perforation of the bowel. For this reason, the need for it should be carefully assessed [3].

Is computed tomography necessary?

Computed tomography is not necessary for every patient with gallstones. Some gallstones may not be clearly visible on CT. However, it can be used to investigate whether the abdominal pain has another cause or to assess complications that have developed.

Treatment Options

Is surgery needed for gallstones that cause no symptoms?

For stones found incidentally on an ultrasound done for another reason, which cause no symptoms and where the gallbladder and bile ducts look normal, surgery is usually not needed. Explaining to the patient which symptoms should prompt them to seek medical attention is usually sufficient [1].

Routine ultrasound at frequent intervals is also not necessary for most patients with asymptomatic stones. If new pain or signs of a complication appear, the situation is reassessed.

However, in the following special situations, the option of surgery may be assessed individually even if there are no complaints at all:

Imaging findings suspicious for gallbladder cancer
Marked or irregular thickening of the gallbladder wall
A polyp in the gallbladder, together with stones, of a size that may require surgery
Very large stones
Certain inherited blood diseases in which red blood cells break down rapidly
Planned treatment that will severely suppress the immune system, or a planned organ transplant
Selected situations in which follow-up or access to emergency healthcare is very difficult

None of these situations on its own means an automatic decision to operate. Age, general state of health, imaging findings and the risks of surgery should be assessed together.

Is surgery always necessary for a porcelain gallbladder?

Calcification of the gallbladder wall is called “porcelain gallbladder”. In the past, this condition was thought to be strongly associated with gallbladder cancer, and surgery was recommended to almost every patient.

Current evidence shows that the cancer risk can vary according to the pattern of calcification. For this reason, surgery is not automatically recommended to every patient with a porcelain gallbladder. The extent of calcification, the appearance of the gallbladder wall, any accompanying polyp or mass, the patient’s age and the risk of surgery should be assessed together.

What is the treatment for gallstones that cause symptoms?

In patients with typical gallstone pain, the definitive treatment is surgical removal of the gallbladder. This procedure is called “cholecystectomy”.

Removing only the stones and leaving the gallbladder in place is not standard treatment, because if the gallbladder, which provides the setting for stone formation, remains, stones can form again.

In the period until planned surgery:

Avoiding very fatty and heavy meals
Limiting foods that the person notices trigger the pain
Using the painkillers recommended by the doctor

can help reduce attacks. However, changes in diet do not remove existing stones.

When is surgery performed for inflammation of the gallbladder?

A gallstone blocking the outlet of the gallbladder can lead to acute cholecystitis, that is, inflammation of the gallbladder. Current guidelines recommend that, if there is no serious condition preventing surgery, laparoscopic surgery be performed as early as possible and preferably during the same hospital admission [2].

Early surgery:

Reduces recurrent attacks of pain and inflammation.
Lowers the risk of returning to hospital.
Can shorten the total length of hospital stay.

In patients whose general condition is severely impaired or who could not tolerate surgery, temporary methods such as antibiotic treatment and draining the gallbladder with a tube placed through the skin may be needed. Once the general condition improves, the possibility of surgery is reassessed.

What happens if a gallstone causes pancreatitis?

A stone that has passed into the bile duct can affect the outlet of the pancreatic duct and lead to acute pancreatitis.

In mild gallstone pancreatitis, gallbladder surgery is usually recommended during the same hospital admission to prevent pancreatitis from developing again [3].

If there is severe pancreatitis, large fluid collections or tissue damage, surgery may be postponed until the inflammation is under control and the patient’s condition has become suitable.

Not every case of gallstone pancreatitis requires urgent ERCP. ERCP is mainly performed when there is ongoing bile duct blockage or bile duct infection [3].

What happens if a stone passes into the bile duct?

If a stone in the common bile duct is confirmed, the stone needs to be cleared. This can be done:

With ERCP before surgery
With a procedure on the bile duct during surgery
In selected patients, with ERCP after surgery

The choice of method depends on the patient’s condition and the experience of the centre.

Even if the bile duct is cleared with ERCP, if there are stones in the gallbladder and the patient is fit for surgery, gallbladder surgery is planned to prevent new stones and complications that may develop later.

How is the operation performed?

The standard surgical method for gallbladder stones is laparoscopic cholecystectomy. The operation is performed under general anaesthesia with a camera and special surgical instruments through a few small incisions in the abdomen.

During the operation, it is important to identify the bile duct and the gallbladder artery safely. An anatomical confirmation method known in surgery as the “critical view of safety” is recommended to reduce the risk of bile duct injury [4].

In the case of severe inflammation, adhesions or anatomy that cannot be safely distinguished, the surgeon may:

Continue part of the operation using the open method.
Remove the part of the gallbladder that can be removed safely.
Carry out an additional investigation during the operation to image the bile ducts.

Converting from keyhole surgery to open surgery is not a failure. This decision is a safety measure taken to prevent serious injury to the bile ducts or blood vessels.

Is robotic surgery necessary?

Gallbladder surgery can be performed laparoscopically, robotically or, in suitable cases, by the open method. Today, the standard and effective approach for most patients is laparoscopic surgery.

A robotic system may be used in some centres, but it is not necessary for every gallbladder operation. For surgical safety, what matters is less the device used and more the correct selection of patients, safe identification of anatomical structures and the surgeon’s experience.

Can the stones be dissolved with medicines?

Medicines containing ursodeoxycholic acid may be considered in very carefully selected patients whose gallbladder works and who have small cholesterol stones. However:

Treatment may need to continue for months or years.
It is not effective for every type of stone.
Stones can form again after treatment.
For stones that cause symptoms, it provides a less lasting solution than surgery.

For this reason, in patients who are fit for surgery and have typical complaints, the standard treatment is usually removal of the gallbladder. Stone-breaking methods are also no longer used routinely for gallbladder stones today.

Do antibiotics treat the stones?

No. Antibiotics do not dissolve or remove gallstones. They can be used to control infection when an infection of the gallbladder or bile duct develops. If the blockage continues, antibiotics alone may not be enough; surgery, ERCP or drainage may be needed.

Recovery

How long do you stay in hospital after the operation?

After an uncomplicated laparoscopic cholecystectomy, many patients can be discharged on the same day or the next day. If there is acute inflammation, another illness, a bile duct stone or open surgery, the length of hospital stay may be longer.

Is there pain after the operation?

In the first days there may be pain at the incision sites and a feeling of tightness in the abdomen. After keyhole surgery, pain radiating to the shoulder may occur because of the gas introduced into the abdomen. These complaints usually ease within a few days.

Using the painkillers recommended by the doctor and taking short walks early on help recovery.

When can you return to normal life and work?

Recovery time varies from person to person. After keyhole surgery, most patients:

Can start light daily activities within a few days.
Can return to desk work within about 1–2 weeks.
Can start driving when they can move without pain, are able to brake suddenly and are not taking strong painkillers.

Heavy lifting, intensive exercise and physically demanding work may require a longer time. The exact timing should be determined according to the course of the operation and the surgeon’s advice.

How should you eat after the gallbladder is removed?

After the gallbladder is removed, the liver continues to produce bile. Bile is no longer stored and flows into the bowel more steadily and in smaller amounts. For this reason, the digestive system continues to work.

In the first days or weeks:

Bloating after fatty meals
Wind
Soft stools
A need to go to the toilet more often

may occur. In most patients, these complaints ease over time.

In the early period, eating small portions and low-fat food can provide comfort. In the long term, most people do not need to follow a strict or special diet. A balanced diet and maintaining a healthy weight are sufficient.

Which symptoms after the operation are important?

If any of the following develops, you should contact the healthcare team:

Abdominal pain that keeps getting worse or does not go away despite painkillers
High fever or shivering
Yellowing of the eyes or skin
Persistent vomiting
Marked swelling of the abdomen
Increasing redness, swelling or pus-like discharge at the wound site
Shortness of breath
One-sided swelling or pain in the leg
Pale stools and dark urine

Frequently Asked Questions

Can gallbladder stones turn into cancer?

Gallbladder stones do not turn directly into cancer. Gallbladder cancer is quite rare. Although long-standing and large stones are thought to possibly increase the risk in connection with chronic inflammation, the vast majority of people with gallstones do not develop cancer.

If irregular thickening of the gallbladder wall, a polyp or a mass is seen on ultrasound, further assessment is needed.

I have stones but no pain at all. Should I have surgery?

Usually not. Routine surgery is not recommended for gallstones that cause no symptoms and where imaging shows no other suspicious finding. It may be enough for you to know which complaints should prompt you to see a doctor.

If there is a large stone, a gallbladder polyp, a change in the wall or certain special conditions, the decision is made individually.

Is regular ultrasound needed for asymptomatic gallstones?

For stones found incidentally in a normal-looking gallbladder that cause no symptoms, regular ultrasound follow-up is not necessary for most patients. If new pain, fever or jaundice develops, a reassessment should be made.

If there is a gallbladder polyp, wall thickening or another suspicious finding, a separate follow-up programme may be needed.

Does the size of a gallstone affect the decision on surgery?

The size of the stone is one of the criteria used in the assessment, but it is not sufficient on its own. The patient’s symptoms, the number of stones, the appearance of the gallbladder wall, any accompanying polyp or mass and the general state of health are assessed together.

Very small stones can also pass into the bile duct and cause pancreatitis or jaundice. For this reason, a clear-cut distinction such as “a small stone is harmless, a large stone is dangerous” cannot be made.

Are many small stones or a single large stone more dangerous?

Both situations can carry different risks. Small stones can pass more easily into the bile duct and cause pancreatitis or jaundice. Large stones, on the other hand, may be associated with long-term pressure and inflammation.

In the decision on surgery, what matters is not only the number and size of the stones but also the symptoms the patient experiences and any complications that develop.

Can a gallbladder stone pass on its own?

A small stone in the gallbladder can pass into the bile duct, but this is not always a good thing. The stone may pass from the duct into the bowel, but it may also block the bile duct or the outlet of the pancreatic duct and cause jaundice, infection or pancreatitis.

Stones that remain inside the gallbladder usually do not disappear completely on their own.

I have biliary sludge; what should I do?

Biliary sludge is the build-up in the gallbladder of small particles in bile such as cholesterol crystals, bilirubin and calcium salts. A distinct stone has not yet formed, but over time biliary sludge may disappear, stay the same or turn into small stones.

Conditions that can make biliary sludge more likely to form are:

Prolonged fasting
Losing weight very quickly
Rapid weight loss after obesity surgery
Pregnancy
Long-term intravenous feeding
Certain serious illnesses
The gallbladder not emptying sufficiently
Use of certain medicines such as ceftriaxone and octreotide

If biliary sludge causes no complaints, immediate surgery or drug treatment is usually not needed. If there is a temporary cause contributing to the formation of sludge, it may disappear on its own once this is corrected. Whether follow-up is needed is determined according to the person’s complaints, blood results and ultrasound findings.

However, biliary sludge is not always harmless. Small crystals can pass into the bile duct and cause:

Typical gallstone pain
Inflammation of the gallbladder
Blockage of the bile duct and jaundice
Bile duct infection
Acute pancreatitis

If there is typical gallstone pain together with biliary sludge, or if a problem such as cholecystitis, jaundice or pancreatitis has developed, and the patient is fit for surgery, the definitive treatment is usually laparoscopic removal of the gallbladder. Surgical assessment is particularly important in patients who have had pancreatitis due to biliary sludge, because of the risk of pancreatitis developing again.

Drug treatment to dissolve biliary sludge is not routinely recommended. Medicines containing ursodeoxycholic acid may be considered only in selected patients who are not fit for surgery or who have special circumstances, by decision of the doctor. You should not use “gallstone-dissolving” medicines or herbal products on your own.

If abdominal pain is accompanied by fever, shivering, jaundice, dark urine or persistent vomiting, you should go to a healthcare facility without waiting [6,7].

Can gallbladder stones be dissolved with medicines?

Drug treatment may be considered only in selected patients who have small cholesterol stones and are not fit for surgery. The treatment takes a long time and there is a possibility of the stones forming again. For stones that cause symptoms, the definitive and established treatment is usually surgery.

Can only the stones be removed during the operation?

In standard treatment, it is not only the stones that are removed but the gallbladder that forms them. If the gallbladder is left in place, the likelihood of new stones forming and complaints returning remains.

Can I live normally without a gallbladder?

Yes. The gallbladder is not an organ that is essential for life. The liver continues to produce bile and the digestive system keeps working. Most patients return to their normal life and usual eating pattern after the operation.

Is the operation done by keyhole surgery?

Today the standard method is laparoscopic, that is, keyhole surgery. In the case of severe inflammation, advanced adhesions, bleeding or anatomical structures that cannot be safely distinguished, the operation may be converted to open surgery.

This change is made for patient safety and does not mean that the operation has failed.

Are gallbladder stones removed with ERCP?

ERCP is mainly used to remove stones that have passed into the common bile duct. ERCP is not the standard treatment for stones inside the gallbladder.

After the bile duct has been cleared with ERCP, if the patient is fit for surgery, a separate operation may be planned for the gallbladder.

Is diarrhoea after gallbladder surgery permanent?

In some patients, stools may temporarily become softer or the frequency of going to the toilet may increase after the operation. This usually lessens over time.

If there is diarrhoea that lasts a long time, affects daily life or wakes you at night, you should see a doctor so that other causes can be investigated and, if necessary, medicines that bind bile acids can be considered.

Do gallstones cause problems in pregnancy?

Gallstones can be found during pregnancy, and some stones can be monitored without causing symptoms. If recurrent pain, inflammation of the gallbladder, jaundice or pancreatitis develops, a joint assessment by the obstetrics and gynaecology, general surgery and anaesthesia teams is needed.

When necessary, laparoscopic surgery can also be performed during pregnancy. The decision is made individually, taking into account the stage of pregnancy, the severity of the illness and the condition of the mother and baby.

Which symptoms mean I should seek urgent care?

In the following situations, go to a healthcare facility without waiting:

Severe abdominal pain that does not go away within a few hours
Pain accompanied by fever or shivering
Yellowing of the eyes or skin
Dark urine
Repeated vomiting
Fainting, marked weakness or confusion

Scientific References

National Institute for Health and Care Excellence (NICE). Gallstone Disease: Diagnosis and Management. Clinical Guideline CG188. London: NICE. https://www.nice.org.uk/guidance/cg188
Pisano M, Allievi N, Gurusamy K, et al. 2020 World Society of Emergency Surgery Updated Guidelines for the Diagnosis and Treatment of Acute Calculous Cholecystitis. World Journal of Emergency Surgery. 2020;15:61. https://pubmed.ncbi.nlm.nih.gov/33153472/
Buxbaum JL, Abbas Fehmi SM, Sultan S, et al. ASGE Guideline on the Role of Endoscopy in the Evaluation and Management of Choledocholithiasis. Gastrointestinal Endoscopy. 2019;89(6):1075–1105.e15. https://pmc.ncbi.nlm.nih.gov/articles/PMC8594622/
Brunt LM, Deziel DJ, Telem DA, et al. Safe Cholecystectomy Multi-Society Practice Guideline and State-of-the-Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy. Surgical Endoscopy. 2020;34:2827–2855. https://www.sages.org/safe-cholecystectomy-program/
Fujita N, Yasuda I, Endo I, et al. Evidence-Based Clinical Practice Guidelines for Cholelithiasis 2021. Journal of Gastroenterology. 2023;58:801–833. https://pmc.ncbi.nlm.nih.gov/articles/PMC10423145/
Gutt C, Schläfer S, Lammert F. The Treatment of Gallstone Disease. Deutsches Ärzteblatt International. 2020;117:148–158. https://pmc.ncbi.nlm.nih.gov/articles/PMC7132079/
European Association for the Study of the Liver (EASL). EASL Clinical Practice Guidelines on the Prevention, Diagnosis and Treatment of Gallstones. Journal of Hepatology. 2016;65(1):146–181. https://pubmed.ncbi.nlm.nih.gov/27085810/

Information note: This page is for general information only. The information here does not replace a personal examination and assessment by a doctor. Decisions about diagnosis and treatment should be made individually, taking into account the patient’s symptoms, examination findings, blood tests, imaging results and general state of health together.