Gallstone Signs and Symptoms

The gallbladder’s function is to store bile from the liver and then secrete it into the small bowel to aid digestion. The gallbladder contracts and secretes in response to certain meals.

What Are the Signs and Symptoms of Gallstones?

Typical signs and symptoms include:

• right upper quadrant pain
• nausea
• vomiting

This is usually associated with fatty meals. If a patient develops these symptoms and has gallstones, it typically requires laparoscopic surgery to remove the gallbladder. This can sometimes be done as an outpatient procedure. Gallstones are generally diagnosed by abdominal ultrasound. With simple gallbladder stones, the liver enzymes are generally normal.

The gallbladder can also cause problems without gallstones. This can come either in the form of biliary dyskinesia with gallbladder pain due to dysfunction or cholecystitis, which is inflammation or infection of the gallbladder. Cholecystitis can be seen on abdominal ultrasound. This will sometimes have abnormal liver enzymes. Biliary dyskinesia, on the other hand, is diagnosed with a HIDA scan, and typically the liver enzymes are normal. A murphy’s sign or tenderness over the gallbladder area is usually associated with cholecystitis.

A fourth issue that is usually handled by a gastroenterologist is common bile duct stones, where either stones have passed out of the gallbladder and are stuck in the bile duct, or stones form in the common bile duct. The common bile duct is the main tube that drains the liver and the gallbladder into the small intestines. Stones in the bile duct can also be associated with infection or cholangitis, which can require emergency intervention by the gastroenterologist.

Most patients do not realize that there is a risk of common bile duct stones even years after the gallbladder has been removed. For the same reason that stones form in the gallbladder, they can also form within the ducts that drain the liver. This risk can be up to 20% of patients. If stones are suspected in the bile duct before surgery, then it is standard practice to clear the bile duct with a procedure called an ERCP before gallbladder surgery. If unexpected bile duct stones are found at the time of surgery, then an ERCP can be performed after surgery.

ERCP stands for endoscopic retrograde cholangiopancreatography. This is an upper endoscopy where a special endoscope is passed to the duodenum just beyond the stomach, where the bile duct and the pancreatic duct can be accessed without surgery.

Further discussion of the technicalities, indications, and risks of ERCP are beyond the scope of this blog. Except in extreme emergencies, there should be a detailed discussion concerning the risk of pancreatitis and bleeding as well as other risks related to an ERCP prior to consideration.

Anatomical changes such as gastric surgery for ulcers or cancer can make this procedure more challenging. Patients’ previous gastric bypass surgery also present with unique challenges. There can be congenital bile duct issues that are not apparent until after surgery. The most common adverse event from laparoscopic gallbladder surgery is not a surgical error but an aberrant bile duct connecting directly from the liver to the gallbladder and is not diagnosable prior to surgery. This problem can be managed after surgery with an ERCP and a temporary stent.

While gallbladder problems are generally a surgical issue, you can see that gastroenterologists get involved with both the diagnosis and peripheral problems related to the gallbladder, bile duct, and pancreas.

Discussion of the pancreas and endoscopic treatment will be the topic of a future blog, but ERCP can also have a significant role in managing pancreatic issues.