Gallstones and gallbladder removal surgery (cholecystectomy)

The gallbladder is a small, pear-shaped organ located under the liver. The liver produces bile throughout the day, and the gallbladder collects and concentrates it. When you eat, especially fatty food, the gallbladder contracts and releases bile into the duodenum. Bile helps digest fats.

Bile itself has a natural tendency to form stones. When its composition is thrown off balance — when there is too much cholesterol, when bile stays in the gallbladder for a long time, or when there is inflammation — crystals form. First a thick “sludge” appears, and then stones develop, from tiny ones the size of a grain of sand to large ones several centimeters across. In medical terms, this condition is called cholelithiasis, and inflammation of the gallbladder is called cholecystitis.

Most gallstones cause no symptoms for many years and are found by chance on an ultrasound. Symptoms usually appear when a stone blocks the outlet of the gallbladder:

• biliary colic — strong, steady pain under the right ribs or in the upper abdomen; it often starts after a fatty or heavy meal, sometimes at night, and lasts from half an hour to several hours;
• pain spreading to the right side of the back, under the shoulder blade and to the right shoulder;
• nausea, sometimes vomiting;
• fever and chills — a sign of gallbladder inflammation (cholecystitis);
• yellowing of the whites of the eyes and the skin, dark urine, pale stools — a sign that a stone has moved into the bile duct.

Bloating, belching, a bitter taste in the mouth and heartburn are more often caused by stomach and esophageal conditions than by gallstones. Pain in the upper abdomen can also be mistaken for a stomach ulcer, inflammation of the pancreas (pancreatitis) or even a heart problem. That is why a diagnosis cannot be made without an examination.

• Sex and hormones: gallstones are more common in women than in men; pregnancy, childbirth and estrogen-containing medications increase the risk.
• Age: the risk rises after the age of 40.
• Weight: excess weight, as well as very rapid weight loss after strict diets or bariatric (weight-loss) surgery.
• Diet: irregular meals, long periods without food, too much fatty and sugary food, too little fiber.
• Medical conditions and heredity: diabetes, liver disease, certain blood disorders, a family history of gallstones.

Although gallstones are less common in men, the inflammation is sometimes more severe in them. In older patients and people with diabetes, inflammation can start with few symptoms and get worse quickly, so they should not delay when symptoms appear.

1. Silent stones. Found on ultrasound, with no symptoms. In most cases, surgery is not needed and monitoring is enough. The exceptions are a very large stone (larger than about 3 cm), a gallbladder with a calcified (“porcelain”) wall and a polyp 1 cm or larger. The doctor assesses these cases individually.
2. Stones that cause symptoms. Once you have had an attack of biliary colic, it often comes back. At this stage, a planned laparoscopic operation is recommended.
3. Acute cholecystitis. Inflammation of the gallbladder shows up as pain that does not ease for hours, along with fever. It requires hospital treatment and, often, surgery within the first few days.
4. Complications. A stone that moves into the bile duct can cause jaundice, a bile duct infection (cholangitis) and inflammation of the pancreas (pancreatitis). In rare cases, tissue in the gallbladder wall dies or the wall ruptures, and the inflammation spreads into the abdominal cavity.

Inflammation that has been left too long and adhesions make a laparoscopic operation, which is usually straightforward, considerably more difficult. This is one of the main reasons not to wait for years with gallstones that cause symptoms.

Gallbladder polyps: does every polyp need surgery?

An ultrasound sometimes shows a polyp attached to the wall of the gallbladder. Most such polyps are benign and do not need surgery: a small polyp that causes no symptoms is usually monitored with ultrasound at set intervals. The main reasons for surgery are a polyp that is 1 cm or larger, grows during monitoring, causes symptoms or looks suspicious on ultrasound. The doctor makes the decision taking into account your age and other risk factors. Do not confuse these with bowel polyps: we cover those on our colon polyps page.

In the following cases, do not take a painkiller and wait at home — seek urgent care:

• pain under the right ribs together with fever and chills;
• yellowing of the whites of the eyes or the skin, dark urine;
• pain that lasts longer than 5–6 hours or keeps getting worse;
• severe, band-like pain that radiates to the back, and repeated vomiting;
• a hard, tense abdomen, severe weakness, confusion.

If pain in the upper abdomen comes with shortness of breath, a cold sweat and tightness in the chest, it may be a heart problem — call an ambulance.

At the appointment, we first ask what the pain is like, when it started and what it followed, and then examine your abdomen. The examination takes a few minutes and is done in private.

• Ultrasound is the main method: it shows stones, polyps, thickening of the gallbladder wall and widening of the bile ducts. The ultrasound is done on an empty stomach, usually after 6–8 hours without food.
• Blood tests: a complete blood count, liver enzymes, bilirubin and pancreatic enzymes. If you have jaundice, bilirubin is always checked.
• MRCP (magnetic resonance cholangiopancreatography) is done if a stone in the bile duct is suspected.
• ERCP (endoscopic retrograde cholangiopancreatography) makes it possible to remove a stone from the bile duct with an endoscope. It is usually planned as a separate procedure, before or after the cholecystectomy.

If you have previous ultrasound or test results, bring them to your appointment. Our contact page explains how to book an appointment and what to bring with you.

Conservative treatment

For silent stones, the main approach is monitoring. During biliary colic, painkillers and antispasmodic medications, and in cholecystitis, antibiotics, bring temporary relief but do not get rid of the stones. A low-fat diet with small, frequent meals can reduce the number of attacks.

Can stones be dissolved with medication? Only in selected cases — small cholesterol stones and a normally functioning gallbladder — can medication taken for months, sometimes years, shrink the stones. The result is often unreliable: after the medication is stopped, the stones frequently form again. That is why the main treatment for gallstones that cause symptoms is surgery.

A “gallbladder cleanse” is dangerous. “Cleanses” with olive oil and lemon juice, “tubage” (a home bile flush) and courses of strong bile-stimulating remedies can push a stone into the bile duct and cause jaundice and pancreatitis.

Surgical and minimally invasive methods

Laparoscopic cholecystectomy is the standard treatment for gallstones that cause symptoms. The operation is done under general anesthesia: you are asleep and feel nothing. The surgeon makes 3–4 small (0.5–1 cm) incisions in the abdomen, one of them near the navel. Carbon dioxide is pumped into the abdominal cavity, and a camera and thin instruments are inserted. The duct and artery of the gallbladder are closed with clips, and the gallbladder is removed together with its stones in a special bag and is usually sent for histological examination.

• Duration: the operation itself usually takes 40–90 minutes, about an hour on average; it may take longer if there is inflammation or adhesions. We will tell you the exact time after the examination. We walk you through the day of surgery step by step in our article on gallbladder surgery.
• The first hours: usually after 4–5 hours you can get out of bed, walk around, and have fluids and light food. Pain can often be controlled with ordinary painkillers.
• Going home: suitable patients go home on the evening of the operation; others usually go home the next day.

Switching to open surgery. In a small number of patients — mainly when there is severe inflammation, adhesions from previous operations, or when the anatomy cannot be seen clearly — the surgeon may switch to an open operation. This is not a failure but a decision made for your safety; recovery simply takes a little longer. If a malignant tumor of the gallbladder is suspected, the surgical plan is made differently and an open approach may be chosen.

Risks. Laparoscopic cholecystectomy is one of the most commonly performed operations and its risk is low, but not zero: bleeding, wound infection, bile leakage, bile duct injury (rare but serious), a stone left behind in the bile duct, and complications related to anesthesia. We discuss these with you separately before the operation.

Combined (“bouquet”) surgery. If, along with gallstones, you have another problem such as an umbilical hernia, hemorrhoids (piles) or an anal fissure, all of them can be treated in the same session when there is a medical indication. This means one anesthetic and one recovery period. More on this: surgical and conservative treatment, combined surgery.

These timeframes are averages; we will give you exact timelines after the examination. If you develop a fever, increasing abdominal pain, jaundice or discharge from a wound, do not wait — seek urgent care.

The gallbladder is not a vital organ. After the operation, the liver keeps producing bile; it simply flows straight into the intestine instead of being stored. Most people return to their usual diet after a few weeks and do not need to follow a strict diet for life. Some people have looser stools after fatty meals in the first weeks, and this usually eases over time. For women: having your gallbladder removed does not prevent a future pregnancy.

In the first weeks, choose soups, porridge, boiled or steamed lean chicken and fish, cooked vegetables and plain yogurt. Limit fried, very fatty and spicy food and fast food for 2–4 weeks, and bring fatty foods back into your diet gradually, in small portions.

1. Eat regularly. Long periods without food make bile stagnate. Eating 3–4 times a day at roughly the same times keeps the gallbladder working regularly.
2. Lose weight gradually. Losing 0.5–1 kg a week is usually recommended; very rapid weight loss and crash diets increase the risk of stones.
3. Eat more fiber: vegetables, fruit, legumes, whole grains.
4. Cut down on saturated fats and sweets. Instead of fried food and animal fat, choose moderate amounts of plant oils such as olive oil.
5. Stay active. At least 30 minutes of walking a day helps you manage your weight and aids digestion.

If you have silent gallstones, these rules can lower the risk of an attack, but they will not dissolve the stones.

Our patient was troubled by aching, burning pain under the right ribs that radiated to the right side of the back and the shoulder. At the same time, going to the toilet caused pain, bleeding and a burning sensation that lasted for hours. The examination revealed gallstones and an anal fissure. Both a cholecystectomy and surgical treatment of the anal fissure were performed in one session. Every patient's situation is different.