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Gall Stone Disease


Gallstones are small, hard deposits that can form in the gallbladder, a sac-like organ that lies under the liver on the right side of the abdomen. Most people with gallstones don't even know they have them. But in some cases a stone may cause the gallbladder to become inflamed, resulting in pain, infection, or other serious complications.

Bile and the Gallbladder

The formation of gallstones is a complex process that starts with bile, a fluid composed mostly of water, bile salts, lecithin (a fat known as a phospholipid), and cholesterol. Most gallstones are formed from cholesterol.

Formation of Gallstones (Cholelithiasis)

The process of gallstone formation is referred to as cholelithiasis. It is generally a slow process, and usually causes no pain or other symptoms. The majority of gallstones are either the cholesterol or mixed type. Gallstones can range in size from a few millimeters to several centimeters in diameter.
Most gallstones are formed from cholesterol. Pigment stones are also very common; they are formed from a brown-colored substance called calcium bilirubinate. Patients can have a mixture of the two gallstone types.
Cholesterol Stones. Although cholesterol makes up only 5% of bile, about three-fourths of the gallstones found in the population are formed from cholesterol. Cholesterol gallstones typically form in the following way:

  • Cholesterol is not very soluble, so in order to remain suspended in fluid it must be transported within clusters of bile salts called micelles. If there is an imbalance between these bile salts and cholesterol, then the bile fluid turns to sludge. This thickened fluid consists of a mucus gel containing cholesterol and calcium bilirubinate.
  • If the imbalance worsens, cholesterol crystals form (a condition called supersaturation), which can eventually form gallstones.

Supersaturation and cholelithiasis can occur as a result of various abnormalities, although the cause is not entirely clear. There are many events that may promote cholelithiasis:

  • The liver secretes too much cholesterol into the bile.
  • The gallbladder may not be able to empty normally, so bile becomes stagnant.
  • The cells lining the gallbladder may not be able to efficiently absorb cholesterol and fat from bile.
  • There are high levels of bilirubin. Bilirubin is a substance normally formed by the breakdown of hemoglobin in the blood. It is removed from the body in bile. Some experts believe bilirubin may play an important role in the formation of cholesterol gallstones.

Pigment Stones. Pigment stones are composed of calcium bilirubinate, or calcified bilirubin. Pigment stones can be black or brown.

  • Black stones form in the gallbladder and are the more common type. They represent 20% of all gallstones in the U.S. They are more likely to develop in people with hemolytic anemia (a relatively rare anemia in which red blood cells are destroyed) or cirrhosis (scarred liver).
  • Brown pigment stones are more common in Asian populations. They contain more cholesterol and calcium than black pigment stones and are more likely to occur in the bile ducts. Infection plays a role in the development of these stones.

Mixed stones. Mixed stones are a mixture of cholesterol and pigment stones.

Choledocholithiasis (Common Bile Duct Stones)

Gallstones can also be present in the common bile duct, rather than the gallbladder. This condition is called choledocholithiasis.

Secondary Common Bile Duct Stones. In most cases, common bile duct stones originally form in the gallbladder and pass into the common duct. They are then called secondary stones. Secondary choledocholithiasis occurs in about 10% of patients with gallstones.
Primary Common Bile Duct Stones. Less often, the stones form in the common duct itself (called primary stones). Primary common duct stones are usually of the brown pigment type and are more likely to cause infection than secondary common duct stones.

Gallbladder Diseases without Stones (Acalculous Gallbladder Disease)

Gallbladder disease can occur without stones, a condition called acalculous gallbladder disease. This refers to a condition in which a person has symptoms of gallbladder stones, yet there is no evidence of stones in the gallbladder or biliary tract. It can be acute (arising suddenly) or chronic (persistent).

  • Acute acalculous gallbladder disease usually occurs in patients who are very ill from other disorders. In these cases, inflammation occurs in the gallbladder. Such inflammation usually results from reduced blood supply or an inability of the gallbladder to properly contract and empty its bile.
  • Chronic acalculous gallbladder disease (also called biliary dyskinesia) appears to be caused by muscle defects or other problems in the gallbladder, which interfere with the natural movements required to empty the sac.


About 90% of gallstones cause no symptoms. There is a very small (2%) chance of developing pain during the first 10 years after gallstones form. After 10 years, the chance for developing symptoms declines. On average, symptoms take about 8 years to develop. The reason for the decline in symptoms after 10 years is not known, although some doctors suggest that "younger," smaller stones may be more likely to cause symptoms than larger, older ones. Acalculous gallbladder disease will often cause symptoms similar to those of gallbladder stones.

Biliary Pain or Colic

The mildest and most common symptom of gallbladder disease is intermittent pain called biliary colic, which occurs either in the mid- or the right portion of the upper abdomen. Symptoms may be fairly nonspecific. A typical attack has several features:

  • The primary symptom is typically a steady gripping or gnawing pain in the upper right abdomen near the rib cage, which can be severe and can radiate to the upper back. Some patients with biliary colic experience the pain behind the breast bone.
  • Nausea or vomiting may occur.
  • Changing position, taking over-the-counter pain relievers, and passing gas do not relieve the symptoms.
  • Biliary colic typically disappears after 1 to several hours. If it persists beyond this point, acute cholecystitis or more serious conditions may be present.
  • The episodes typically occur at the same time of day, but less frequently than once a week. Large or fatty meals can trigger the pain, but it usually occurs several hours after eating and often awakens the patient during the night.
  • The condition commonly returns, but attacks can be years apart.

Digestive complaints such as belching, feeling unusually full after meals, bloating, heartburn (burning feeling behind the breast bone), or regurgitation (acid back-up in the food pipe) are not likely to be caused by gallbladder disease. Conditions that may cause these symptoms include peptic ulcer, gastroesophageal reflux disease, or indigestion of unknown cause.

Symptoms of Gallbladder Inflammation (Acute Calculous and Acalculous Cholecystitis)

Between 1 and 3% of people with symptomatic gallstones develop inflammation in the gallbladder (acute cholecystitis), which occurs when stones or sludge block the duct. The symptoms are similar to those of biliary colic but are more persistent and severe. They include the following:

  • Pain in the upper right abdomen that is severe and constant, and may last for days. Pain frequently increases when drawing a breath.
  • Pain may also radiate to the back or occur under the shoulder blades, behind the breast bone, or on the left side.
  • About a third of patients have fever and chills.
  • Nausea and vomiting may occur.

Anyone who experiences such symptoms should seek medical attention. Acute cholecystitis can progress to gangrene or perforation of the gallbladder if left untreated. Infection develops in about 20% of patients with acute cholecystitis, and increases the danger from this condition. People with diabetes are at particular risk for serious complications.

Symptoms of Chronic Cholecystitis or Dysfunctional Gallbladders

Chronic gallbladder disease (chronic cholecystitis) involves gallstones and mild inflammation. In such cases the gallbladder may become scarred and stiff. Symptoms of chronic gallbladder disease include the following:

  • Complaints of gas, nausea, and abdominal discomfort after meals; these are the most common symptoms, but they may be vague and difficult to distinguish from similar complaints in people who do not have gallbladder disease.
  • Chronic diarrhea (4 - 10 bowel movements every day for at least 3 months).

Symptoms of Stones in the Common Bile Duct (Choledocholithiasis)

Stones lodged in the common bile duct can cause symptoms that are similar to those produced by stones that lodge in the gallbladder, but they may also cause the following symptoms:

  • Jaundice (yellowish skin)
  • Dark urine, lighter stools, or both
  • Rapid heartbeat and abrupt blood pressure drop
  • Fever, chills, nausea and vomiting, and severe pain in the upper right abdomen. These symptoms suggest an infection in the bile duct (called cholangitis).

As in acute cholecystitis, patients who have these symptoms should seek medical help immediately. They may require emergency treatment.

Prognosis and Complications:

Gallstones that do not cause symptoms rarely lead to problems. Death, even from gallstones with symptoms, is very rare. Serious complications may occur. If they do occur, complications usually develop from stones in the bile duct, or after surgery.
Gallstones, however, can cause obstruction at any point along the ducts that carry bile. In such cases, symptoms can develop.

  • In most cases of obstruction, the stones block the cystic duct, which leads from the gallbladder to the common bile duct. This can cause pain (biliary colic), infection and inflammation (acute cholecystitis), or both.
  • About 10% of patients with symptomatic gallstones also have stones that pass into and obstruct the common bile duct (choledocholithiasis).


The most serious complication of acute cholecystitis is infection, which develops in about 20% of cases. It is extremely dangerous and life threatening if it spreads to other parts of the body (a condition called septicemia), and surgery is often required. Symptoms include fever, rapid heartbeat, fast breathing, and confusion. Among the conditions that can lead to septicemia are the following:

  • Gangrene or Abscesses. If acute cholecystitis is untreated and becomes very severe, inflammation can cause abscesses. Inflammation can also cause necrosis (destruction of tissue in the gallbladder), which leads to gangrene. The highest risk is in men over 50 who have a history of heart disease and high levels of infection.
  • Perforated Gallbladder. An estimated 10% of acute cholecystitis cases result in a perforated gallbladder, which is a life-threatening condition. In general, this occurs in people who wait too long to seek help, or in people who do not respond to treatment. Perforation of the gallbladder is most common in people with diabetes. The risk for perforation increases with a condition called emphysematous cholecystitis, in which gas forms in the gallbladder. Once the gallbladder has been perforated, pain may temporarily decrease. This is a dangerous and misleading event, however, because peritonitis (widespread abdominal infection) develops afterward.
  • Empyema. Pus in the gallbladder (empyema) occurs in 2 - 3% of patients with acute cholecystitis. Patients usually experience severe abdominal pain for more than 7 days. The physical exam often fails to reveal the cause. The condition can be life-threatening, particularly if the infection spreads to other parts of the body.
  • Fistula. In some cases, the inflamed gallbladder adheres to and perforates nearby organs, such as the small intestine. In such cases a fistula (channel) between the organs develops. Sometimes, in these cases, gallstones can actually pass into the small intestine, which can be very serious and requires immediate surgery.
  • Gallstone Ileus. A gallstone blocking the intestine is known as gallstone ileus. It primarily occurs in patients over age 65, and can sometimes be fatal. Depending on where the stone is located, surgery to remove the stone may be required.
  • Infection in the Common Bile Duct (Cholangitis). Infection in the common bile duct from obstruction is common and serious. If antibiotics are administered immediately, the infection clears up in 75% of patients. If cholangitis does not improve, the infection may spread and become life-threatening. Either surgery or a procedure known as endoscopic sphincterotomy is required to open and drain the ducts. Those at highest risk for a poor outlook also have one or more of the following conditions:
    • Kidney failure
    • Liver abscess
    • Cirrhosis
    • Over 50 years old
  • Pancreatitis. Common bile duct stones are responsible for most cases of pancreatitis (inflammation of the pancreas), a condition that can be life threatening. The pancreatic duct, which carries digestive enzymes, joins the common bile duct right before it enters the intestine. It is therefore not unusual for stones that pass through or lodge in the lower portion of the common bile duct to obstruct the pancreatic duct.

Other Complications

Gallbladder Cancer: Gallstones are present in about 80% of people with gallbladder cancer. There is a strong association between gallbladder cancer and cholelithiasis, chronic cholecystitis, and inflammation. Symptoms of gallbladder cancer usually do not appear until the disease has reached an advanced stage and may include weight loss, anemia, recurrent vomiting, and a lump in the abdomen.
Research shows that survival rates for gallbladder cancer are on the rise, although the death rate remains high because many people are diagnosed when the cancer is already at a late stage. When the cancer is caught at an early stage and has not spread beyond the mucosa (inner lining), removing the gallbladder (resection) can cure many people with the disease. If the cancer has spread beyond the gallbladder, other treatments may be required.
This cancer is very rare, even among people with gallstones. Certain conditions in the gallbladder, however, contribute to a higher-than-average risk for this cancer.
Gallbladder Polyps. Polyps (growths) are sometimes detected during diagnostic tests for gallbladder disease. Small gallbladder polyps (up to 10 mm) pose little or no risk, but large ones (greater than 15 mm) pose some risk for cancer, so the gallbladder should be removed. Patients with polyps 10 - 15 mm have a lower risk, but they should still discuss gallbladder removal with their doctor.
Porcelain Gallbladders. Gallbladders are referred to as porcelain when their walls have become so calcified (covered in calcium deposits) that they look like porcelain on an x-ray. Porcelain gallbladders have been associated with a very high risk of cancer, although recent evidence suggests that the risk is lower than was previously thought. This condition may develop from a chronic inflammatory reaction that may actually be responsible for the cancer risk. The cancer risk appears to depend on the presence of specific factors, such as partial calcification involving the inner lining of the gallbladder.

Physical Examination

In patients with known gallstones, the doctor can often diagnose acute cholecystitis (gallbladder inflammation) based on classic symptoms (constant and severe pain in the upper right part of the abdomen). Imaging techniques are necessary to confirm the diagnosis. There is usually no tenderness in chronic cholecystitis.

Laboratory Tests

Blood tests are usually normal in people with simple biliary colic or chronic cholecystitis. The following abnormalities may indicate gallstones or complications:

  • Bilirubin and the enzyme alkaline phosphatase are usually elevated in acute cholecystitis, and especially in choledocholithiasis (common bile duct stones). Bilirubin is the orange-yellow pigment found in bile. High levels of bilirubin cause jaundice, which gives the skin a yellowish tone.
  • Levels of liver enzymes known as aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are elevated when common bile duct stones are present.

A high white blood cell count is a common finding in many (but not all) patients with cholecystitis.

Imaging and Diagnostic Techniques

Ultrasound of the Abdomen. Ultrasound is a simple, rapid, and noninvasive imaging technique. It is the diagnostic method most frequently used to detect gallstones and is the method of choice for detecting acute cholecystitis. If possible, the patient should not eat for 6 or more hours before the test, which takes only about 15 minutes. During the procedure, the doctor can check the liver, bile ducts, and pancreas, and quickly scan the gallbladder wall for thickening (characteristic of cholecystitis).
How well ultrasound can help in the diagnosis varies based on the patient's situation:

  • Ultrasound accurately detects gallstones as small as 2 mm in diameter. Some experts recommend that the test be repeated if an ultrasound does not detect stones, but the health care provider still strongly suspects gallstones.
  • Air in the gallbladder wall may indicate gangrene.
  • Ultrasound does not appear to be very useful for identifying cholecystitis in patients who have symptoms but do not have gallstones.
  • Ultrasound is also not as accurate for identifying common bile duct stones or imaging the cystic duct. Nevertheless, normal ultrasound results, along with normal bilirubin and liver enzyme tests are very accurate indications that there are no stones in the common bile duct.

X-Rays. Standard x-rays of the abdomen may detect calcified gallstones and gas. Variations include oral cholecystography or cholangiography.

  • In oral cholecystography, the patient takes a tablet containing a dye the night before the test. The dye fills the gallbladder, and x-ray images are taken the next day. The test has largely been replaced by ultrasound; however, it may be useful in some cases for determining the structural and functional status of the gallbladder, often before nonsurgical procedures.
  • In cholangiography, a dye is injected into the bile duct and x-rays are used to view the duct. It is typically used during operations to provide a clear image of the biliary tract.

Computed Tomography. Computed tomography (CT) scans may be a valuable additional imaging technique if the doctor suspects complications, such as perforation, common duct stones, or other problems such as cancer in the pancreas or gallbladder. Helical (spiral) CT scanning is an advanced technique that is faster and obtains clearer images. With this process, the patient lies on a table while a donut-like, low-radiation x-ray tube rotates around the patient.
Magnetic Resonance Cholangiography (MRCI), or Magnetic Resonance Cholangiopancreatography (MRCP). These imaging techniques may be very useful for detecting common bile duct stones and other abnormalities of the biliary tract. MRCP is extremely sensitive in detecting biliary tract cancer. This imaging procedure may not detect very small stones or chronic infections in the pancreas or bile duct. It is most likely to be useful in a small subset of patients who have unclear symptoms that suggest gallbladder or biliary tract problems, but ultrasound and other routine tests have been negative. For these patients, performing a MRCP can eliminate the need for ERCP and its side effects.

Endoscopic Retrograde Cholangiopancreatography (ERCP). Endoscopic retrograde cholangiopancreatography (ERCP) has been the gold standard for detecting common bile duct stones, particularly because stones can be removed during the procedure. However, this technique is invasive and carries a risk for complications, including pancreatitis. With the advent of noninvasive imaging techniques, ERCP is now generally limited to patients who have a high likelihood of common bile ducts stones, which would need to be removed. It may also be used to diagnose biliary dyskinesia.


Acute pain from gallstones and gallbladder disease is usually treated in the hospital, where diagnostic procedures are performed to rule out other conditions and complications. There are three approaches to gallstone treatment:

  • Expectant management ("wait and see")
  • Surgical removal of the gallbladder

Expectant Management of Asymptomatic Gallstones

Guidelines from the American College of Physicians state that when a person has no symptoms, the risks of both surgical and nonsurgical treatments for gallstones outweigh the benefits. Experts suggest a wait-and-see approach, which they have termed expectant management, for these patients. Exceptions to this policy are people who at risk for complications from gallstones, including the following:

  • Those at risk for gallbladder cancer
  • Pima Native Americans
  • Patients with stones larger than 3 cm

One study reported that very small gallstones increase the risk for acute pancreatitis, a serious condition. Some experts therefore believe that gallstones smaller than 5 mm warrant immediate surgery.
There are some minor risks with expectant management for people who do not have symptoms or who are at low risk. Gallstones almost never spontaneously disappear, except sometimes when they are formed under special circumstances, such as pregnancy or sudden weight loss. At some point, the stones may cause pain, complications, or both, and require treatment. Some studies suggest the patient's age at diagnosis may be a factor in the possibility of future surgery. The probabilities are as follows:

  • 15% likelihood of future surgery at age 70
  • 20% likelihood of future surgery at age 50
  • 30% likelihood of future surgery at age 30

The slight risk of developing gallbladder cancer might encourage young adults who do not have symptoms to have their gallbladder removed.

Symptomatic patients

Gallstones are the most common cause for emergency room and hospital admissions of patients with severe abdominal pain. Many other patients experience milder symptoms. Results of diagnostic tests and the exam will guide the treatment, as follows:
Normal Test Results and No Severe Pain or Complications. Patients with no fever or serious medical problems who show no signs of severe pain or complications and have normal laboratory tests may be discharged from the hospital with oral antibiotics and pain relievers.
Gallstones and Presence of Pain (Biliary Colic) but No Infection. Patients who have pain and tests that indicate gallstones, but who do not show signs of inflammation or infection have the following options:

  • Intravenous painkillers for severe pain.
  • Elective gallbladder removal. Patients may electively choose to have their gallbladder removed (called cholecystectomy) at their convenience.
  • Drug therapy. Drug therapy for gallstones is available for some patients who are unwilling to undergo surgery, or who have serious medical problems that increase the risks of surgery. Recurrence rates are high with nonsurgical options, and the introduction of laparoscopic cholecystectomy has greatly reduced the use of nonsurgical therapies. Note: Drug treatments are generally inappropriate for patients who have acute gallbladder inflammation or common bile duct stones, because delaying or avoiding surgery could be life threatening.

Acute Cholecystitis (Gallbladder Inflammation). The first step if there are signs of acute cholecystitis is to "rest" the gallbladder in order to reduce inflammation. This involves the following treatments:

  • Fasting
  • Intravenous fluids and oxygen therapy
  • Strong painkillers,
  • Intravenous antibiotics. These are administered if the patient shows signs of infection, including fever or an elevated white blood cell count, or in patients without such signs who do not improve after 12 - 24 hours.

People with acute cholecystitis almost always need surgery to remove the gallbladder. The most common procedure now is laparoscopy, a less invasive technique than open cholecystectomy (which involves a wide abdominal incision). Surgery may be done within hours to weeks after the acute episode, depending on the severity of the condition.

Gallstone-Associated Pancreatitis. Patients who have developed gallstone-associated pancreatitis almost always have a cholecystectomy during the initial hospital admission or very soon afterwards. For gallstone pancreatitis, immediate surgery may be better than waiting up to 2 weeks after discharge, as current guidelines recommend. Patients who delay surgery experience a high rate of recurrent attacks before their surgery.
Common Duct Stones. If noninvasive diagnostic tests suggest obstruction from common duct stones, the doctor will perform endoscopic retrograde cholangiopancreatography (ERCP) to confirm the diagnosis and remove stones. This technique is used along with antibiotics if infection is present in the common duct (cholangitis). In most cases, common duct stones are discovered during or after gallbladder removal.

Management of Common Bile Duct Stones

Common bile duct stones pose a high risk for complications and nearly always warrant treatment. There are various options available. It is not clear yet which one is best.

  • In the past, when common bile duct stones were suspected, the approach was open surgery (open cholecystectomy) and surgical exploration of the common bile duct. This required a wide abdominal incision.
  • Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) is now the most frequently used procedure for detecting and managing common bile duct stones. The procedure involves the use of an endoscope (a flexible telescope containing a miniature camera and other instruments), which is passed down the throat to the bile duct entrance.
  • Laparoscopic choledocholithotomy also is increasingly being used for the detection and removal of common bile duct stones. This is an approach through the abdomen, but it uses small incisions instead of one large incision. It is used in combination with ultrasound or a cholangiogram (an imaging technique in which a dye is injected into the bile duct and moving x-rays are used to view any stones).

Experts are currently debating the choice between laparoscopy and ERCP. Many surgeons believe that laparoscopy is becoming safe and effective, and should be the first choice. Still, laparoscopy for common bile duct stones should only be performed by surgeons who are experienced in this technique.

Dissolution Therapies

Oral drugs used to dissolve gallstones and lithotripsy (alone or in combination with other drugs) gained popularity in the 1990s. Oral medications have lost favor with the increased use of laparoscopy, but they may still have some value in specific circumstances.
Oral Dissolution Therapy. Oral dissolution therapy uses bile acids in pill form to dissolve gallstones, and may be used in conjunction with lithotripsy, although both techniques are rarely used today. Ursodiol (ursodeoxycholic acid, Actigal, UDCAl) and chenodiol (Chenix) are the standard oral bile acid dissolution drugs. Most doctors prefer ursodeoxycholic acid, which is considered to be one of the safest common drugs. Long-term treatment appears to notably reduce the risk of biliary pain and acute cholecystitis. The treatment is only moderately effective, however, because gallstones return in the majority of patients.
Patients most likely to benefit from oral dissolution therapy are those who have small stones (less than 1.5 cm in diameter) with a high cholesterol content.
Patients who probably will not benefit from this treatment include obese patients and those with gallstones that are calcified or composed of bile pigments.
Only about 30% of patients are candidates for oral dissolution therapy. The number may actually be much lower, because compliance is often a problem. The treatment can take up to 2 years and can cost thousands of dollars per year.


The gallbladder is not an essential organ, and its removal is one of the most common surgical procedures performed on women. It can even be performed on pregnant women with low risk to both the baby and mother. The primary advantages of surgically removing the gallbladder over nonsurgical treatment are that it can eliminate gallstones and prevent gallbladder cancer.
Open Procedures Versus Laparoscopy. Until the early 1990s, open cholecystectomy (the removal of the gallbladder through a wide abdominal incision) was the standard treatment. Now, laparoscopic cholecystectomy (commonly called lap choly), which uses small incisions, is the most commonly used surgical approach.
Laparoscopy has largely replaced open cholecystectomy because it offers some significant advantages:

  • The patient can leave the hospital and resume normal activities earlier, compared to open surgery.
  • The incisions are small, and there is less postoperative pain and disability than with the open procedure.
  • There are fewer complications.
  • It is less expensive than open cholecystectomy over the long term. The immediate treatment cost of laparoscopy may be higher than the open procedure, but the more rapid recovery and fewer complications translate into shorter hospital stays and fewer sick days, and therefore a greater reduction in overall costs.

Some experts believe, however, that the open procedure still has a number of advantages compared to laparoscopy:

  • It is faster to perform.
  • It poses less of a risk for bile duct injury compared with laparoscopy. However, open surgery has more overall complications than laparoscopy, and bile-duct injury rates with laparoscopy are declining.

The type of surgery performed on specific patients may vary depending on different factors.
Appropriate Surgical Candidates. Candidates for gallbladder removal often have, or have had, one of the following conditions:

  • A very severe gallstone attack
  • Several less severe gallstone attacks
  • Endoscopic sphincterotomy for common bile duct stones (in patients with residual gallbladder stones)
  • Cholecystitis (gallbladder inflammation)
  • Pancreatitis (inflammation of the pancreas) secondary to gallstones
  • High risk for gallbladder cancer (such as patients with anomalous junction of the pancreatic and biliary ducts or patients with certain forms of porcelain gallbladder)
  • Chronic acalculous gallbladder disease (also called biliary dyskinesia), in which the gallbladder does not empty well and causes biliary colic, even though there are no gallstones present

The best candidates are those with evidence of impaired gallbladder emptying.
Pregnant women who have gallstones and experience symptoms are also candidates for surgery.
Timing of Surgery. Cholecystectomy may be performed within days to weeks after hospitalization for an acute gallbladder attack, depending on the severity of the condition.

  • Emergency gallbladder removal within 24 - 48 hours is warranted in about 20% of patients with acute cholecystitis. Indications for surgery include deterioration of the patient's condition, or signs of perforation or widespread infection.
  • Under debate is what type of surgery and timing are most appropriate for patients with acute cholecystitis whose condition improves and who have no signs of severe complications. Previously, the standard was open cholecystectomy between 6 - 12 weeks after the acute episode. Some evidence now suggests that patients who have early surgery (performed between 72 - 96 hours after symptoms begin) have fewer complications than those who wait to have surgery.

General Outlook. Although cholecystectomy is very safe, as with any operation there are risks of complications, depending on whether the procedure is done on an elective or emergency basis.

  • When cholecystectomy is performed as an elective surgery, the mortality rates are very low. (Even in the elderly, mortality rates are only 0.7 - 2%.)
  • Emergency cholecystectomy has a much higher mortality rate (as high as 19% in ill elderly patients).

Long-Term Effects of Gallbladder Removal. Removal of the gallbladder has not been known to cause any long-term adverse effects, aside from occasional diarrhea.

Laparoscopic Cholecystectomy

The Procedure. With laparoscopy, gallbladder removal is typically performed as follows:

  • Laparoscopic cholecystectomy requires general anesthesia, although it is now mostly done as outpatient surgery.
  • The surgeon inserts a needle through the navel and pumps carbon dioxide gas through it to create space in the abdomen. This step may raise blood pressure. Antihypertensive drugs may be helpful during surgery to protect patients who have high blood pressure or heart or kidney disease.
  • One or two 10 - 12 mm (about one-half inch) and three 5 mm (about one-fifth of an inch) incisions are made in the abdomen.
  • The surgeon inserts a laparoscope (a thin telescope), which contains a small surgical instrument and a tiny camera that relays an image to a video monitor.
  • The surgeon separates the gallbladder from the liver and other areas, and removes it through one of the incisions.
  • Evidence suggests that the use of cholangiography during the operation helps prevent injury in the bile ducts, a serious complication of cholecystectomy. With this procedure, dye is injected into the bile duct, and moving x-rays are used to view the duct.
  • Often patients will need to stay in the hospital overnight. However, some patients can go home the same day.

Risk Factors for Conversion from Laparoscopy to an Open Procedure. In about 5 - 10% of laparoscopies, conversion to open cholecystectomy is required during the procedure. The rate of conversion to open surgery is higher in men than in women. This may be due to the higher rate of inflammation and fibrosis in men with symptomatic gallstones. Other reasons for conversion from laparoscopic to open surgery include:

  • Possible or known injury to major blood vessels
  • Internal structures are not clearly visible
  • Unexpected problems that cannot be corrected with laparoscopy
  • Common bile duct stones that cannot be removed with laparoscopy or subsequent ERCP
  • Previous endoscopic sphincterotomy
  • A thickened gallbladder wall

Complications and Side Effects of Surgery

  • Pain and fatigue are common side effects of any abdominal surgery. Patients should avoid light recreational activities for about 2 days and from work and more strenuous activities for about a week.
  • There is a relatively high incidence of nausea and vomiting after laparoscopic cholecystectomy, which can be treated with injections of metoclopramide. Patients may take anti-nausea medications such as granisteron before surgery to help prevent these effects. Local anesthesia at the incision sites (in addition to general anesthesia) before surgery may reduce pain and nausea afterwards.
  • Injury to the bile duct is the most serious complication of laparoscopy. It can include leakage, tears, and the development of narrowing (strictures) that can lead to liver damage. In order to minimize such injuries, some experts recommend that surgeons perform laparoscopy with cholangiography. Bile duct injury has been a more common problem in laparoscopy compared to the open procedure, but increasing surgical experience and the use of cholangiography is reducing this complication. Studies are reporting more comparable rates between the two procedures.
  • In about 6% of procedures, the surgeon misses some gallstones, or they spill and remain in the abdominal cavity. In a small percentage of these cases, the stones cause obstruction, abscesses, or fistulas (small channels) that require open surgery.
  • As with all surgeries, there is a risk for infection, but it is very low.

Patients should not be shy about inquiring into the number of laparoscopies the surgeon has performed (the minimum should be 40). Obese patients were originally thought to be poor candidates for laparoscopic cholecystectomy, but recent research indicates that this surgery is safe for them.

Open Cholecystectomy

Before the development of laparoscopy, the standard surgical treatment for gallstones was open cholecystectomy (surgical removal of the gallbladder through an abdominal incision), which requires a wide incision and leaves a large surgical scar. In this procedure, the patient usually stays in the hospital for 5 - 7 days and may not return to work for a month. Complications include bleeding, infections, and injury to the common bile duct. The risks of this procedure increase with other factors, such as the age of the patient, or the need to explore the common bile duct for stones at the same time.
Candidates for whom cholecystectomy may be a more appropriate choice:

  • Patients who have had extensive previous abdominal surgery
  • Patients with complications of acute cholecystitis (empyema, gangrene, perforation of the gallbladder)

Older patients. Patients who are over 80 years old are likely to have lower complication rates from open cholecystectomy than laparoscopy, although laparoscopy may also be appropriate in these patients.
Whether or not to insert a drain in the wound after surgery is under debate. Many surgeons implant drains to prevent abscesses or peritonitis. That practice may change. One analysis found that patients who received drains had a dramatically increased risk of wound and chest infection, regardless of the type of drain used.

ERCP with Endoscopic Sphincterotomy (ES)

Reasons for performing the procedure:

  • Before gallbladder surgeries, when there is a strong suspicion that common bile duct stones are present.
  • At the end of a cholecystectomy, if the surgeon detects stones in the common bile duct (only if there are experts in ERCP present, and equipment is available).
  • For patients with gallstone cholangitis (serious infection in the common bile duct). In such cases urgent ERCP and antibiotics are required.
  • When acute pancreatitis is caused by gallstones, urgent ERCP, along with antibiotics, may be used. The use of ERCP compared to conservative treatment has been controversial.

The ERCP and ES Procedure. A typical ERCP and endoscopic sphincterotomy (ES) procedure includes the following steps:

  • The patient is given a sedative and asked to lie on his or her left side.
  • An endoscope (a tube containing fiber optics connected to a camera) is passed through the mouth and stomach and into the duodenum (top part of the small intestine) until it reaches the point where the common bile duct enters. This does not interfere with breathing, but the patient may have a sensation of bloating.
  • A thin catheter (tube) is then passed through the endoscope.
  • Contrast material (a dye) is injected through the catheter into the opening of the duct. The dye allows x-ray visualization of the biliary tree (the system of ducts through which bile flows, including the common bile duct) and any stones contained in the area.
  • Instruments may also be passed through the endoscope to remove any stones that are detected.
  • The next phase of the procedure is known as endoscopic sphincterotomy (ES). (It is also sometimes referred to as papillotomy, although this is a slightly different variation.) ES widens the junction between the common bile duct and intestine (the ampulla of Vater) so that the stones can be extracted more easily. With ES, a tiny incision is usually made in the opening of the common bile duct and through the muscles that enclose the lower common bile duct (the sphincter of Oddi).
  • One recent alternative to ES is the use of a small inflatable balloon (a procedure known as endoscopic balloon dilation) that opens up the ampulla of Vater to allow stones to pass. This variation does not involve cutting muscles.
  • Once the junction has been opened, the stones may pass on their own, or they may be extracted with the use of tiny baskets or balloons.

Complications. Complications of ERCP and ES occur in 5 - 8% of cases, and some can be serious. Mortality rates are 0.2 - 0.5%. Complications include the following:

  • Pancreatitis (inflammation of the pancreas) occurs in 3 - 9% of cases and can be very serious. Younger adults are at higher risk than the elderly. The risk is also higher with more complex procedures. The drugs somatostatin or gabexate are sometimes used to reduce the risk, although recent evidence suggests somatostatin may not actually reduce this risk. Gabexate appears to be more effective, although studies are mixed on whether its benefits are significant, particularly with short-term treatment.
  • Postoperative infection. Antibiotics may be given before the procedure to prevent infection, although one study reported that they had little benefit.
  • Bleeding occurs in 2% of cases. There is an increased risk for bleeding in patients taking anti-clotting drugs, and those who have cholangitis. This complication is treated by flushing the area with epinephrine.
  • Perforations (rare)
  • Long-term complications include stone recurrence and abscesses.

ERCP and ES are difficult procedures, and patients must be certain that their doctor and medical center are experienced. ERCP can usually be performed successfully by an experienced surgeon, even in critically ill patients who are on mechanical ventilators.
ERCP and Gallbladder Removal (Cholecystectomy). ERCP is often performed after gallstones in the common duct are discovered during cholecystectomy.
In some cases, stones in the gallbladder are detected during ERCP. In such cases, laparoscopic cholecystectomy is usually warranted. There is some debate about whether the gallbladder should be removed at the same time as ERCP, or if patients should wait.