Gallstones: When to Operate

Gallstones are far more common than most people realise. A significant proportion of adults have them and will go through their entire lives without any related symptoms or problems. The discovery of gallstones, often incidentally during an ultrasound done for an unrelated reason, raises a question that does not always have a straightforward answer: do they need to come out?

The decision on when to operate on the gallbladder depends not on the presence of gallstones alone, but on whether they are causing symptoms, what complications have developed, and what the risk of future problems looks like for the individual patient.

What gallstones are and how they form?

The gallbladder is a small organ beneath the liver that stores bile, a digestive fluid produced by the liver. Gallstones form when the components of bile, primarily cholesterol,  become too concentrated and crystallise into solid deposits. They range in size from tiny fragments to stones the size of a golf ball.

Between 10 and 15 out of every 100 people have gallstones, but most do not even realise it. The majority remain completely asymptomatic throughout a person's lifetime. The problem arises when a stone moves into the bile duct or irritates the gallbladder, triggering symptoms or complications.

Gallstone symptoms that indicate the need for assessment

The characteristic symptom of gallstones is biliary colic, a sudden, severe pain in the upper right abdomen that often radiates to the right shoulder or back. It typically comes on after a fatty meal, can last from 30 minutes to several hours, and then resolves. Nausea and vomiting frequently accompany the pain.

Other gallstone symptoms that warrant medical attention include:

• Recurring episodes of upper right abdominal pain lasting more than 15 to 30 minutes
• Jaundice, where the skin and whites of the eyes turn yellow, indicating a stone blocking the bile duct
• Dark urine and pale stools, which accompany bile duct obstruction
• Fever accompanying abdominal pain, which suggests the gallbladder or bile ducts have become infected

When surgery is clearly indicated

Surgery, known as cholecystectomy, is indicated when stones cause significant symptoms or complications. If there are no symptoms, there is no indication to operate.

The clearest indications for gallstones surgery include:

• Recurrent biliary colic

If a patient has had several episodes of typical gallbladder pain lasting more than 15 to 30 minutes and interfering with normal life, surgery is appropriate because it is very likely that episodes will repeat and worsen over time. Once gallstones have caused a symptomatic episode, the probability of recurrence is high, and the risk of complications increases with each attack.

• Acute cholecystitis

Acute cholecystitis occurs when a stone obstructs the cystic duct and the gallbladder becomes inflamed and infected. It produces severe, persistent upper right abdominal pain, fever, and tenderness on examination. Acute cholecystitis requires immediate surgery, preferably during the same hospitalisation. Early laparoscopic cholecystectomy within 72 hours of gallstone symptom onset is now the standard recommendation in most guidelines, as delaying surgery is associated with higher complication rates.

• Common bile duct stones

When gallstones migrate into the common bile duct, they obstruct the flow of bile from the liver and can cause jaundice, cholangitis (infection of the bile ducts), or acute pancreatitis. These are serious complications requiring urgent intervention. The stone is typically removed first using a procedure called ERCP (endoscopic retrograde cholangiopancreatography), followed by cholecystectomy to remove the gallbladder and prevent recurrence.

• Gallstone pancreatitis

When a stone temporarily blocks the opening of the pancreatic duct, it can trigger acute pancreatitis. Once the pancreatitis has settled, cholecystectomy is recommended before discharge from hospital to prevent a recurrence, which carries significant risk of a more severe episode.

Asymptomatic gallstones: when to watch and when to act

Despite only approximately 20% of gallstones becoming symptomatic, the widespread availability of abdominal ultrasound has made asymptomatic gallstones a common incidental finding. For most people with asymptomatic gallstones, watchful waiting is appropriate. The risk of developing complications without prior symptoms is low, and surgery carries its own risks that outweigh the benefit in low-risk patients.

However, certain groups with asymptomatic gallstones may be recommended early elective surgery because their risk of developing serious complications is higher:

• Patients with a single very large gallstone, as these carry a higher risk of gallbladder cancer
• Patients with a porcelain gallbladder, where calcium deposits in the gallbladder wall are associated with increased cancer risk
• Patients in areas where gallbladder cancer rates are higher than average
• Patients who will be undergoing bariatric surgery, in whom gallstone formation and complications are more likely after rapid weight loss

What gallbladder removal involves

Gallbladder removal, known as cholecystectomy, is the only reliable long-term solution for gallstones. It is one of the most common procedures performed worldwide, usually as a laparoscopic surgery. A person can live well without a gallbladder. Bile simply flows directly from the liver to the small intestine rather than being stored first.

Laparoscopic cholecystectomy is a minimally invasive surgical procedure. It involves small cuts, a camera, and surgical tools. Most patients are discharged within a day following the surgery. Recovery is usually swift and most patients return to normal activity within a week or two.

Takeaways

Indications for surgery for gallstones are recurrent symptoms, acute cholecystitis, bile duct obstruction and gallstone pancreatitis. Asymptomatic gallstones are not usually an indication for surgery in persons at low risk and can be handled by attentive waiting.

Symptoms of gallstones include recurrent upper right abdomen discomfort, jaundice and fever with abdominal tenderness and these symptoms should prompt urgent medical assessment. Cholecystectomy is the definitive treatment for gallbladder condition. Laparoscopic surgery offers a safe, effective and well-tolerated route to permanent resolution of the problem.