What are gallstones and who gets them?

Gallstones are solid concretions that form in the gallbladder — most commonly cholesterol stones (approximately 75-80% in Western populations, formed when bile becomes supersaturated with cholesterol) or pigment stones (black — from chronic haemolysis or cirrhosis; brown — from biliary infection and stasis, more common in Asia). Approximately 10-15% of Western adults have gallstones. Risk factors include: female sex; increasing age; obesity; rapid weight loss (including after bariatric surgery — hence prophylactic ursodeoxycholic acid in that setting); pregnancy and multiparity; family history; type 2 diabetes; certain drugs (ceftriaxone, octreotide, fibrates); ileal disease or resection; and haemolytic disorders. Approximately 80% of people with gallstones never develop symptoms.

Do asymptomatic gallstones need surgery?

No — in the overwhelming majority of cases. Gallstones found incidentally on ultrasound or CT performed for another reason do not require cholecystectomy: the annual rate of developing symptoms is only approximately 1-2%, and prophylactic surgery exposes the patient to operative risk (including the 0.3-0.5% risk of bile duct injury) without net benefit. Exceptions where prophylactic cholecystectomy IS considered: gallbladder polyps ≥10mm (or ≥6mm with risk factors); porcelain (calcified) gallbladder; stones >3cm; anomalous pancreaticobiliary duct junction; patients awaiting organ transplantation or undergoing bariatric surgery in some protocols; and in regions of very high gallbladder cancer incidence, per local guidance. Symptomatic gallstones — biliary colic, cholecystitis, pancreatitis, cholangitis — should be treated with cholecystectomy.

What is the difference between biliary colic and cholecystitis?

Biliary colic: a stone temporarily obstructs the cystic duct, then falls back. Severe constant pain in the right upper quadrant or epigastrium (the name "colic" is misleading — the pain is steady, not intermittent), often radiating to the right shoulder blade, frequently after a fatty meal, lasting 30 minutes to a few hours and then resolving completely. No fever, no systemic upset, normal white cell count and CRP. Treated with analgesia and elective cholecystectomy. Acute cholecystitis: the obstruction is sustained, so the gallbladder wall becomes inflamed and infected. Pain persists beyond 6 hours, with fever, a positive Murphy's sign, raised white cells and CRP, and ultrasound showing a thickened gallbladder wall and pericholecystic fluid. This requires admission, IV antibiotics and early laparoscopic cholecystectomy — ideally within 72 hours of symptom onset.

What are the risks of gallbladder surgery?

Laparoscopic cholecystectomy is one of the most commonly performed operations worldwide and is generally safe. Risks: bile duct injury (approximately 0.3-0.5% — the most serious complication, with substantial long-term morbidity; prevented by achieving the critical view of safety before dividing any structure, and by converting or performing subtotal cholecystectomy when the anatomy cannot be defined); bile leak; bleeding; infection; retained CBD stone; conversion to open surgery (approximately 5%, higher in severe cholecystitis, male sex, obesity, previous surgery); and post-cholecystectomy syndrome (persistent symptoms in approximately 10-15% — frequently due to unrecognised bile acid diarrhoea, functional gut disorder or an alternative diagnosis that was mistakenly attributed to the gallstones in the first place).

How does GMJ News cover gallstone disease?

GMJ News covers gallstone epidemiology and risk factors, the asymptomatic-stone rule (no surgery), biliary colic vs acute cholecystitis, Tokyo Guidelines TG18 severity grading, early vs delayed cholecystectomy (ACDC trial), acute cholangitis and urgent drainage, choledocholithiasis pathways (MRCP/EUS before ERCP), post-ERCP pancreatitis prophylaxis, index cholecystectomy after gallstone pancreatitis (PONCHO trial), the critical view of safety and bile duct injury prevention, Mirizzi syndrome, and gallbladder cancer indications. Directly relevant to PHIG's surgical safety and gastroenterology programme.

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Gallstones and Biliary Disease

Q: What is cholangitis and why is it an emergency?

Acute cholangitis is bacterial infection of an obstructed biliary tree — usually caused by a stone in the common bile duct, sometimes by a stricture or tumour. It is a surgical and endoscopic emergency because pus under pressure in an obstructed duct system rapidly produces bacteraemia and septic shock. Charcot's triad — fever, jaundice and right upper quadrant pain — is present in around 50-70%; Reynolds' pentad adds hypotension and confusion, indicating suppurative cholangitis. Management: resuscitation, blood cultures and broad-spectrum IV antibiotics — but the definitive treatment is urgent biliary decompression, usually ERCP with sphincterotomy and stone extraction, within 24 hours (within 12 hours in severe cases). Antibiotics alone cannot sterilise an obstructed system; delay in drainage is the principal determinant of mortality.

GMJ News knowledge hub · last reviewed August 2026 · Georgian Medical Journal

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Gallstone disease — the formation of cholesterol or pigment stones within the gallbladder — affects approximately 10-15% of adults in Western populations, of whom around 80% remain asymptomatic for life, but the symptomatic minority generate one of the highest surgical workloads in general surgery worldwide, with laparoscopic cholecystectomy among the most frequently performed operations globally (WHO). The critical clinical distinctions are between biliary colic (transient cystic duct obstruction, self-limiting, no fever or inflammatory markers), acute cholecystitis (sustained obstruction with gallbladder wall inflammation — Tokyo Guidelines severity grading; early laparoscopic cholecystectomy within 72 hours is superior to delayed surgery), choledocholithiasis (common bile duct stone — requires ERCP) and acute cholangitis (Charcot’s triad — a biliary emergency requiring urgent biliary drainage and carrying substantial mortality if decompression is delayed).

Key messages

10-15% of Western adults have gallstones — 80% remain asymptomatic for life

Gallstone prevalence: approximately 10-15% of adults in Western populations; higher in Latin America and among Native American populations; lower in sub-Saharan Africa and East Asia. Approximately 80% remain asymptomatic indefinitely, and asymptomatic gallstones found incidentally on imaging do NOT require cholecystectomy (annual rate of developing symptoms: approximately 1-2%). Risk factors ("the 5 Fs" is an outdated and imprecise mnemonic): female sex, increasing age, obesity, rapid weight loss, pregnancy and multiparity, family history, diabetes, ceftriaxone, octreotide, ileal disease or resection (bile salt malabsorption), haemolysis (pigment stones).

Distinguish biliary colic from acute cholecystitis — the diagnostic fork

Biliary colic: transient cystic duct obstruction by a stone that then falls back. Severe, constant (not colicky despite the name) right upper quadrant or epigastric pain, often radiating to the right scapula, lasting 30 minutes to several hours, then resolving completely. NO fever, NO systemic upset, normal WCC and CRP. Acute cholecystitis: sustained obstruction → gallbladder wall inflammation. Pain persisting >6 hours, fever, positive Murphy's sign (inspiratory arrest on RUQ palpation), raised WCC and CRP, gallbladder wall thickening and pericholecystic fluid on ultrasound. This distinction determines whether the patient needs urgent admission and surgery or elective referral.

Early laparoscopic cholecystectomy beats delayed surgery in acute cholecystitis

For acute cholecystitis, early laparoscopic cholecystectomy (within 72 hours of symptom onset, and certainly within the index admission) is superior to initial conservative management with delayed interval surgery: shorter total hospital stay, no increase in conversion or complication rate, and avoidance of the substantial proportion of patients who represent with recurrent or complicated disease while awaiting interval surgery (ACDC trial, Ann Surg 2013; Cochrane). Tokyo Guidelines (TG18) grade severity: Grade I (mild — no organ dysfunction); Grade II (moderate — marked local inflammation, WCC >18, palpable mass, >72h duration); Grade III (severe — organ dysfunction). Grade III with prohibitive operative risk: percutaneous cholecystostomy as a temporising measure.

Acute cholangitis — Charcot's triad is a biliary emergency

Acute cholangitis: infection of an obstructed biliary tree. Charcot's triad — fever, jaundice, right upper quadrant pain (present in approximately 50-70%). Reynolds' pentad adds hypotension and confusion — indicating suppurative cholangitis with septic shock. Mortality without decompression is very high. Management: resuscitation; blood cultures; broad-spectrum IV antibiotics; and — the definitive intervention — URGENT BILIARY DRAINAGE, usually ERCP with sphincterotomy and stone extraction, within 24 hours (within 12 hours for Grade III/severe). Antibiotics alone do not treat an obstructed infected biliary system; delay in decompression is the principal driver of mortality.

Common bile duct stones — predict, then image, then ERCP

Choledocholithiasis (CBD stone) should be suspected with: jaundice; raised bilirubin and ALP (cholestatic pattern); dilated CBD (>6mm, or >8-10mm post-cholecystectomy) on ultrasound; history of pancreatitis or cholangitis. Investigation pathway: high probability → ERCP directly (therapeutic); intermediate probability → MRCP or endoscopic ultrasound (EUS) first (both highly sensitive, non-invasive, avoid unnecessary ERCP); low probability → proceed to cholecystectomy with or without intraoperative cholangiography. ERCP carries a 3-5% risk of post-ERCP pancreatitis — it should be therapeutic, not diagnostic.

Index cholecystectomy after gallstone pancreatitis — do not discharge without it

After an episode of gallstone pancreatitis, laparoscopic cholecystectomy should be performed during the SAME admission (index cholecystectomy) for mild disease, or within 2 weeks — because the risk of recurrent biliary events (recurrent pancreatitis, cholecystitis, cholangitis) while awaiting delayed surgery is substantial (approximately 15-30% within 6 weeks). The PONCHO trial (Lancet 2015) confirmed same-admission cholecystectomy significantly reduced recurrent gallstone-related complications versus interval surgery. For necrotising or severe pancreatitis, cholecystectomy is deferred until collections have resolved or stabilised.

Key statistics

10-15%

gallstone prevalence in Western adult populations

WGO/SAGES

~80%

of gallstones remain asymptomatic — incidental stones do NOT need surgery

WGO/NICE

<72 hours

target for early laparoscopic cholecystectomy in acute cholecystitis (superior to delayed)

ACDC/Tokyo TG18

Charcot triad

fever + jaundice + RUQ pain = acute cholangitis = urgent biliary drainage within 24h

Tokyo TG18

3-5%

risk of post-ERCP pancreatitis — ERCP should be therapeutic, not diagnostic

ESGE/ASGE

PONCHO 2015

same-admission cholecystectomy after gallstone pancreatitis reduces recurrent events (Lancet)

Lancet 2015

Gallstone disease — clinical presentations and required urgency

Source: Tokyo Guidelines TG18 / WGO. Cholangitis is the most time-critical; asymptomatic stones need no intervention.

Glossary of key terms

Tokyo Guidelines (TG18) severity grading
Surgery/HepatobiliaryThe international standard for grading acute cholecystitis and cholangitis severity. Acute cholecystitis: Grade I (mild) — no organ dysfunction, mild local inflammation; Grade II (moderate) — WCC >18×10⁹/L, palpable tender RUQ mass, duration >72 hours, marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, biliary peritonitis, emphysematous cholecystitis); Grade III (severe) — dysfunction in any of: cardiovascular (vasopressor requirement), neurological, respiratory (PaO2/FiO2 <300), renal (creatinine >176 μmol/L), hepatic (INR >1.5), haematological (platelets <100). Grading determines whether early cholecystectomy, drainage or intensive support is required first.

Murphy's sign
Clinical examinationThe examiner places fingers below the right costal margin at the mid-clavicular line and asks the patient to inspire deeply. As the inflamed gallbladder descends onto the examining hand, the patient experiences sharp pain and abruptly stops inspiration — a positive Murphy's sign. Sensitivity approximately 65%, specificity approximately 87% for acute cholecystitis in adults; substantially less reliable in the elderly (who may present with minimal signs and normal inflammatory markers despite advanced gangrenous cholecystitis) and in patients on corticosteroids. Sonographic Murphy's sign (maximal tenderness elicited by the ultrasound probe directly over the visualised gallbladder) has higher accuracy than the clinical sign.

Critical view of safety (CVS)
Surgical safetyThe standard technique to prevent bile duct injury — the most feared complication of laparoscopic cholecystectomy (incidence approximately 0.3-0.5%, with severe long-term morbidity). Three criteria must ALL be met before any structure is clipped or divided: (1) The hepatocystic triangle is cleared of fat and fibrous tissue; (2) The lower third of the gallbladder is separated from the cystic plate (liver bed); (3) Exactly TWO structures are seen entering the gallbladder — the cystic duct and cystic artery, and no others. If the CVS cannot be achieved (severe inflammation, fibrosis, Mirizzi syndrome), the correct action is to convert to open surgery, perform a subtotal (fenestrating or reconstituting) cholecystectomy, or abandon and drain — never to proceed on assumption.

Mirizzi syndrome
HepatobiliaryExtrinsic compression of the common hepatic duct by a large stone impacted in Hartmann's pouch or the cystic duct, causing obstructive jaundice. Csendes classification: Type I — external compression only; Types II-IV — progressive cholecystocholedochal fistula formation with increasing erosion into the common duct wall. Clinical importance: it produces obstructive jaundice with gallstones but no CBD stone on imaging; it dramatically increases the risk of bile duct injury during cholecystectomy (the anatomy is distorted and inflammation is dense); it is associated with gallbladder carcinoma in approximately 5-28% of cases. Preoperative recognition (MRCP) allows appropriate operative planning — usually subtotal cholecystectomy, sometimes open, occasionally with bilioenteric reconstruction.

Gallbladder cancer and porcelain gallbladder
Oncology/SurgeryGallbladder adenocarcinoma is uncommon but highly lethal (5-year survival <10% when not incidental) — with striking geographical variation (very high incidence in northern India, Chile, Bolivia, Poland; low in Western Europe and North America). Gallstones are present in 70-90% of cases. Indications for prophylactic cholecystectomy in ASYMPTOMATIC gallstones: gallbladder polyps ≥10mm (or ≥6mm with risk factors — age >50, sessile morphology, Indian ethnicity, primary sclerosing cholangitis); porcelain gallbladder (calcified wall — though the associated cancer risk has been revised downward from historical figures, selective/incomplete calcification still warrants cholecystectomy); stones >3cm; anomalous pancreaticobiliary junction; and in some settings, chronic typhoid carriage.

ERCP indications and post-ERCP pancreatitis prophylaxis
Endoscopy/ESGEERCP should be therapeutic, not diagnostic — MRCP and EUS have replaced diagnostic ERCP. Indications: choledocholithiasis (extraction); acute cholangitis (urgent decompression); gallstone pancreatitis with cholangitis or persistent obstruction; malignant biliary obstruction (stenting); bile leak. Post-ERCP pancreatitis (PEP): incidence 3-5%, higher in young women, difficult cannulation, sphincter of Oddi dysfunction, pancreatic duct injection. Prophylaxis (ESGE): rectal indomethacin or diclofenac 100mg immediately before or after ERCP for ALL patients without contraindication (reduces PEP by approximately 50%); aggressive periprocedural Lactated Ringer's hydration; prophylactic pancreatic duct stent in high-risk cases.

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