Gallstones: symptoms, treatment and surgery decisions

Gallstones are small stones that form in the gallbladder or bile ducts, and most never cause symptoms. They matter when they block bile flow, causing biliary colic, gallbladder inflammation, jaundice, bile duct infection or pancreatitis. If gallstones are causing repeated pain or complications, the usual definitive treatment is laparoscopic gallbladder removal, not a supplement, cleanse or permanent low-fat diet.¹²

What gallstones are

The gallbladder stores bile, a fluid made by the liver that helps digest fat. Gallstones form when substances in bile, usually cholesterol or bilirubin, harden into stones. They can sit quietly inside the gallbladder, block the cystic duct from the gallbladder, or move into the common bile duct, where bile drains towards the small intestine. The same stone can therefore be harmless, painful or dangerous depending on where it is.

NHS guidance says gallstones may be found in the gallbladder or bile ducts, and most people with gallstones do not get symptoms.¹ NICE is clear on this point: people with asymptomatic gallbladder stones in a normal gallbladder and normal biliary tree should be reassured that they do not need treatment unless symptoms develop.² This matters because incidental scan findings are common, and not every stone needs surgery.

Risk is higher with age over 40, female sex, obesity, diabetes, Crohn's disease, rapid weight loss and a diet high in fat and low in fibre, according to NHS guidance.¹ Hormonal factors, pregnancy, family history, ethnicity, bariatric surgery and some medicines can also affect risk. But risk factors are not destiny. The clinical question is whether the stones match the symptom pattern.

Symptoms and red flags

The classic symptom is biliary colic. The word "colic" can be misleading because the pain is often steady rather than crampy. NHS guidance describes pain that is severe, constant, lasts longer than 30 minutes and up to several hours, sits in the middle of the tummy or under the right ribs, and may make you feel sick or vomit.¹ It commonly starts after eating, especially a fatty meal, but it can happen without an obvious trigger.

Gallstone pain is often confused with reflux, indigestion, IBS, food intolerance, gastritis, ulcer disease, heart pain, liver disease, pancreatitis and kidney stones. Location helps, but it is not enough. Pain that is new, severe, persistent, associated with vomiting, fever, jaundice or abnormal liver blood tests needs assessment.

One complication to respect is acute pancreatitis. NHS pancreatitis guidance says acute pancreatitis is a serious condition needing urgent hospital treatment, and gallstones are one of the most common causes because they can block the opening of the pancreas.⁴ Pancreatitis pain is often sudden, severe, persistent, in the upper abdomen and can spread to the back.

How gallstones are diagnosed

NICE recommends liver function tests and ultrasound for suspected gallstone disease, including people with abdominal or gastrointestinal symptoms that have not responded to previous management.² Ultrasound is good at finding gallbladder stones and signs of inflammation. Liver blood tests help show whether the bile ducts may be obstructed.

If ultrasound does not show common bile duct stones but the bile duct is dilated or liver function tests are abnormal, NICE says to consider MRCP, an MRI scan focused on the bile and pancreatic ducts. If MRCP still does not make the diagnosis and suspicion remains, NICE says to consider endoscopic ultrasound.² This stepwise approach matters because a stone inside the gallbladder and a stone blocking the common bile duct are managed differently.

Blood tests may also check inflammation, infection, bilirubin, liver enzymes, pancreatic enzymes and kidney function. If pain is atypical, tests may need to look for other causes. NICE explicitly advises further investigations if conditions other than gallstone disease are suspected.²

Treatment decisions

If gallstones are not causing symptoms, treatment is usually unnecessary. If gallstones are causing symptoms, NICE recommends offering laparoscopic cholecystectomy, removal of the gallbladder through keyhole surgery.² NHS guidance also describes surgery to remove the gallbladder as the main treatment for gallstones that cause symptoms or complications.¹

People often ask whether the stone itself can be removed while keeping the gallbladder. In routine UK practice, the usual operation removes the gallbladder because the gallbladder is the stone-forming reservoir. Removing only stones leaves the mechanism behind and recurrence is likely. There are special circumstances, but most symptomatic gallbladder stones are treated by cholecystectomy.

For acute cholecystitis, NICE recommends early laparoscopic cholecystectomy, carried out within 1 week of diagnosis.² A Cochrane review by Gurusamy and colleagues found six randomised trials with 488 participants fit for laparoscopic surgery. Early surgery did not show significant differences in bile duct injury, serious complications or conversion to open surgery compared with delayed surgery, and total hospital stay was about 4 days shorter in the early group, though the trials were at high risk of bias.⁵

If a stone is in the common bile duct, NHS guidance says ERCP may be used to clear the duct.¹ NICE recommends bile duct clearance and laparoscopic cholecystectomy for symptomatic or asymptomatic common bile duct stones, with duct clearance either surgically at cholecystectomy or by ERCP before or at the time of surgery.² ERCP clears the duct; it does not remove the gallbladder.

Diet, weight loss and prevention

Diet can reduce attacks while you are waiting, but it usually does not make established gallstones disappear. NHS advice while waiting for surgery includes avoiding foods that trigger symptoms and being advised to eat a low-fat diet.¹ NICE says to avoid food and drink that triggers symptoms until the gallbladder or gallstones are removed, but people should not need to avoid those triggers after recovery unless symptoms persist or new symptoms develop.²

Rapid weight loss is a real gallstone risk. NIDDK explains that fast weight loss can make the liver secrete extra cholesterol into bile and can stop the gallbladder emptying properly; very low-calorie diets and weight-loss surgery can therefore increase risk.³ If you are losing weight for health reasons, slower, planned weight loss with enough fibre and medical support is safer than repeated crash diets.

After gallbladder removal, most people can digest food without a special permanent diet because bile still reaches the gut, but it is no longer stored and released in the same way. Some people get temporary diarrhoea, bloating or fat intolerance while the body adapts. Persistent diarrhoea after cholecystectomy can be bile acid diarrhoea, not IBS by default, and should be discussed with a GP.

Prevention is therefore practical rather than mystical: avoid crash dieting, maintain a healthy weight, increase fibre, choose unsaturated fats more often than very high saturated-fat meals, keep diabetes risk under review, and seek assessment for recurrent right upper abdominal pain rather than masking it with antacids. Low-fat eating may reduce attacks while waiting, but extremely low-fat dieting can make meals miserable and is not the same as curing stones.

A practical plan

Start with symptom matching. Gallstones found on a scan are meaningful only if the pain pattern fits. Ask: where is the pain, how long does it last, does it follow meals, does it radiate to the back or shoulder blade, is there vomiting, fever, jaundice, dark urine or pale stools, and have liver tests been abnormal?

Then clarify the anatomy. Are the stones only in the gallbladder, or is there a common bile duct stone? Is the gallbladder inflamed? Is the bile duct dilated? Are pancreatic enzymes raised? The answers determine whether the next step is planned gallbladder surgery, urgent admission, MRCP, ERCP, antibiotics, pancreatitis care or a search for another diagnosis.

If you are comparing gallbladder symptoms with reflux, IBS, fatty liver, pancreatitis, kidney stones or medication side effects, the health library can help map the overlap. The start here guide is useful before a GP or surgical appointment, while insights can help separate evidence-based care from cleanse marketing. If you are taking bile salts, TUDCA, digestive enzymes, herbal products, painkillers or weight-loss supplements, check the plan with the stack builder before combining products.

This article is educational and does not constitute medical advice, diagnosis, or a treatment recommendation. Medication uses described as “off-label” are not licensed for that purpose in the UK and should only be considered under qualified clinical supervision. Always speak to your GP, pharmacist, or a registered specialist before starting, stopping, or changing any treatment. If you have severe or alarm symptoms - unintentional weight loss, blood in your stool, difficulty swallowing, persistent vomiting, a fever, or severe pain - seek urgent medical care.