Gallstones are solid concretions that form within the gallbladder as a result of precipitation and crystallisation of bile constituents. They are classified into three main types: cholesterol stones the most common, accounting for over 80% of cases in Western populations, forming when bile becomes supersaturated with cholesterol relative to bile salts and phospholipids; pigment stones subdivided into black pigment stones (associated with haemolytic anaemia and cirrhosis) and brown pigment stones (associated with bile duct infection and biliary stasis); and mixed stones, containing both cholesterol and calcium salts. Well-established risk factors follow the classic "5 Fs" Fat, Forty, Female, Fertile and Family history alongside additional factors including rapid weight loss, prolonged fasting, diabetes mellitus and ileal disease or resection impairing bile salt reabsorption. Gallstones are remarkably prevalent, affecting approximately 10–15% of the adult population, yet the majority remain asymptomatic throughout life.
Symptoms
Approximately 80% of individuals with gallstones remain entirely asymptomatic, with stones discovered incidentally on abdominal imaging. When symptoms develop, the characteristic presentation is biliary colic a severe, cramping pain in the right upper quadrant or epigastrium, typically occurring 30–60 minutes after a fatty meal as the gallbladder contracts against an obstructing stone in the cystic duct. The pain often radiates to the right shoulder tip or interscapular region and may be accompanied by nausea and vomiting. Episodes last between 30 minutes and several hours before resolving spontaneously. Progression to acute cholecystitis infection and inflammation of the gallbladder produces persistent right upper quadrant pain, fever and a positive Murphy's sign on examination (inspiratory arrest on deep palpation of the right upper quadrant). Further complications include choledocholithiasis (stones migrating into the common bile duct), causing obstructive jaundice, dark urine and pale stools, and acute cholangitis a life-threatening infection of the biliary tree presenting with Charcot's triad of fever, jaundice and right upper quadrant pain.
Diagnosis
Abdominal Ultrasound is the first-line and most sensitive investigation for gallstones, demonstrating hyperechoic foci with posterior acoustic shadowing within the gallbladder along with any associated gallbladder wall thickening or pericholecystic fluid indicating cholecystitis. Liver function tests (LFTs) including bilirubin, ALP and GGT are measured to detect biliary obstruction suggestive of common bile duct stones. MRCP (Magnetic Resonance Cholangiopancreatography) is the gold standard non-invasive investigation for visualising the biliary tree and confirming choledocholithiasis before surgical or endoscopic intervention. CT scan plays a limited role in uncomplicated gallstone disease but is valuable in assessing complications such as perforation, emphysematous cholecystitis or Mirizzi syndrome.
Treatment
Asymptomatic gallstones in the general population do not require treatment and are managed expectantly as the annual risk of developing symptoms is low at approximately 1–2%. Once symptomatic, Laparoscopic Cholecystectomy keyhole surgical removal of the gallbladder is the definitive and curative treatment of choice. Performed under general anaesthesia through three to four small port incisions, it is one of the most commonly performed elective surgical procedures worldwide, offering rapid recovery, minimal post-operative pain and an excellent safety profile. For acute cholecystitis, early laparoscopic cholecystectomy within 72 hours of symptom onset is now the preferred approach, demonstrating superior outcomes over delayed surgery. When common bile duct stones are confirmed, ERCP (Endoscopic Retrograde Cholangiopancreatography) with sphincterotomy and stone extraction is performed either pre-operatively or as a laparoscopic intraoperative cholangiogram before proceeding to cholecystectomy to clear the biliary tree completely. Ursodeoxycholic acid dissolution therapy offers a non-surgical alternative for small cholesterol stones in patients unfit for surgery, though recurrence rates are high and its role remains limited.