By Wendy Haaf
When Dara Speigel, 50, of Toronto, began having stomach aches early in 2024, she assumed her body was reacting to stress. There had recently been cancer diagnoses and deaths in her immediate family, and she had not only learned that she carries a genetic mutation that significantly increases her risk for breast and ovarian cancers but also undergone surgery to prevent the latter. Eventually, however, Speigel consulted her doctor about her symptoms and went for an ultrasound.
“Even though the technician isn’t supposed to say anything, she said, ‘It’s very evident that you have gallstones,’” Speigel says. In retrospect, Speigel realized that what she’d thought was a bout of food poisoning earlier in the year had been a gallstone attack. “It had me on the floor in the fetal position in the middle of the night, wondering if I was going to throw up,” she says. After a few hours, the excruciating pain suddenly stopped.
An estimated 10 to 15 per cent of North American adults over age 40 have gallstones at any given time, but these hard deposits of material that form in the gallbladder don’t always cause problems. In fact, “75 per cent of people who develop stones will never have consequences from stone disease—only 25 per cent do,” says Dr. Gurpal Sandha, a professor and gastroenterologist in the Faculty of Medicine and Dentistry at the University of Alberta in Edmonton. How- ever, there’s no way to predict which patients with gall- stones will fall into which category. So here’s what you need to know about how gallstones form, what happens during a gallstone attack, and how they’re treated.
How They Form
“Gallstones form from crystals in the bile,” explains Dr. Lawrence Hookey, president of the Canadian Association of Gastroenterology and division chair and professor in the Department of Medicine at Queen’s University in Kingston, Ont. A substance that plays a crucial role in digesting fat, bile is produced in the liver and then travels through a small tube into the gallbladder, where it’s stored. When you eat a meal containing fat and the food reaches the small bowel, “a hormone is released that stimulates the contraction of the gallbladder,” Hookey says. This squeezes bile out of the gallbladder, through another small tube, and into the small bowel. The bile “mixes with the food and helps digest and absorb the fat.”
Bile contains a number of components, including cholesterol and bilirubin. In addition to its many other essential roles in the body, cholesterol is used to make fat- dissolving bile acids, and bilirubin is a waste product formed during the normal breakdown of red blood cells.
There are two main types of gallstones: cholesterol stones, which are the most common, and pigment stones, which are primarily made of bilirubin.
Gallstones begin to form when a specific trio of circumstances occur together. The first is an imbalance in the chemistry of the bile. Typically, it becomes “super saturated” with cholesterol. The second essential element is what Sandha calls a nidus—the cholesterol or bilirubin “needs to crystallize around something,” he explains. “It might be products of bacteria that creep into the bile or mucoproteins [the building blocks of mucus].” The final puzzle piece is a lack of movement of the bile. “I liken it to a lake versus a river,” Hookey explains. “The gallbladder is the lake, where things can sit around for a bit longer than in the bile duct, which is the river.” If crystals do form, they can grow into “stones that come in different sizes,” he says. “Some can stay small—say, one or two millimetres—and some can grow up to one or two centimetres.”
There is some evidence that certain dietary factors and exercise may reduce the likelihood of developing gallstones. For example, a small number of studies have linked higher intakes of dietary fibre, vegetable protein, monounsaturated fats (one source being olive oil), vitamin C, magnesium, and coffee with lower rates of gallstones.
On the other hand, certain risk factors can increase the likelihood of gallstone formation. Age is one: the number of new cases is four times higher among people aged 40 to 69 than among younger adults.
Before menopause, women are three to four times more likely to develop gallstones than are men of the same age. After menopause, this gap narrows; however, taking menopausal hormone therapy is linked with an increased risk. These differences are thought to be due at least in part to the fact that female hormones increase cholesterol saturation in bile and reduce contraction of the gallbladder.
Other factors linked with higher cholesterol concentration in bile and increased gallstone risk are rapid weight loss and obesity. Ethnicity plays a role in susceptibility, too. Gallstone prevalence is higher among those of Scandinavian descent and people of North and South American Indigenous ancestry. Dieting and bariatric surgery are also linked with an increased risk. “If you’re not eating enough, the gallbladder isn’t pumping out bile, so it stagnates,” Sandha says. The same thing can happen after weight-loss surgery because the stomach can hold very little; in the case of certain operations, food bypasses the gallbladder entirely, he adds. And a number of medical conditions, including some anemias and severe liver disease, can saturate the bile with bilirubin, raising the risk for pigment stones.
“I asked my specialist why I would get gallstones,” Speigel says. “I don’t match the criteria, other than being female, over 40, and taking hormones—but many women who take them don’t get gallstones. His response was that anyone can get them.”
When They Attack
Once stones form, they don’t cause problems if they stay put. However, sometimes they can migrate either into the cystic duct, which exits the gallbladder, or farther down, past where the cystic duct drains into the larger common bile duct, which runs from the liver to the pancreas and then the intestine.
What’s typically happening during a gallstone attack is this. After you ingest fat, the gallbladder contracts, propelling a stone into either the cystic duct or the bile duct. The smooth muscle walls of these structures contract in an effort to move the stone. “The stone can get stuck and unstuck, and that can give you pain, nausea, and vomiting,” Hookey says. The pain is known medically as biliary colic. Attacks tend to come on about 30 minutes after eating— often following a large or fatty meal—last for minutes to several hours, and then simply stop.
Most commonly, “the pain is in the upper right side of the abdomen, just below the rib cage, which then seems to radiate around the side, to the right shoulder blade,” Sandha says. However, not everyone experiences these textbook symptoms. Speigel, for instance, says the pain was so intense she couldn’t localize it. Mike Waddingham, 60, of Burnaby, B.C., says the sensation he felt during his first gallstone attacks roughly 20 years ago was more like “an intense pressure centralized below the sternum.”
“Some people find that their attacks can be triggered by dietary indiscretions—so the classic, rich, heavy meal,” says Dr. James R. Gray, a Vancouver gastroenterologist and medical adviser for the Gastrointestinal Society. “But in fact, it’s a minority of people who can provoke an attack by eating certain foods or prevent attacks by eating differently. There are no dietary factors that will make the stones go away once they’re formed.”
In most cases, the gallstone will either return to the gallbladder or make its way to the intestine and eventually get excreted with food waste. However, while some people might experience only a single attack, “for reasons that aren’t clear, if you’ve had one, you’re more likely to get another,” Gray says. According to one 2010 study, two out of three people who have a first attack of pain or other symptoms go on to have subsequent attacks.
If you experience one or two bouts of symptoms resembling those mentioned above, see your primary-care provider. If gallstones are the leading suspect, your doctor will likely send you for an abdominal ultrasound. (Most gallstones don’t contain calcium and therefore don’t show up on X-rays, but they’re usually visible on ultrasound.) If imaging confirms the presence of gallstones, a referral to a surgeon is usually the next step.
“If you’re having typical attacks and they’re troublesome enough or frequent enough, then the treatment would be to remove the gallbladder,” Gray says. “That’s the only meaningful way to alleviate gallbladder attacks. Generally people do very well without a gallbladder.” Without the gallbladder acting as a reservoir, bile flows directly from the liver into the common bile duct. This slight rerouting doesn’t impair the digestion of fat, but some patients’ bodies take time to adjust to the change. An estimated “10 to 15 per cent of people report diarrhea after gallbladder surgery,” Gray says. “People usually get over it in time,” Sandha adds, “and nothing special needs to be done about it.”
Discussing your options with your health-care provider sooner rather than later can help prevent complications that, while relatively uncommon, can be dangerous in themselves and increase the complexity and risks of surgery. These problems arise when a stone becomes lodged in one of the small tubes leading away from the gallbladder. Depending on size, a stone “can either cause a blockage of the exit of the gallbladder—the cystic duct—or cause a blockage in the bile duct,” Hookey says. “If it gets stuck and stays in either of those two places for even a day or two, that can result in an infection of the gallbladder or the bile duct. That’s what we call cholecystitis and cholangitis.” These situations “are more concerning and become more of an emergency,” Gray says.
If the stone sticks in the bile duct, this “obstructs the flow of bile from the liver to the intestine, so the bile backs up into the liver, causes inflammation, and then spills into the bloodstream,” Sandha says. This can lead to a number of serious complications. (Seek immediate medical attention if your urine turns dark or the whites of your eyes take on a yellowy tinge, since these are signals of such a blockage.) Blood tests can help with diagnosis, since “the liver enzymes are all elevated,” Sandha says.
Occasionally, a stone can wander even farther downstream into the duct that drains from the pancreas into the small intestine. This causes inflammation in the pancreas, known as pancreatitis. “Gallstones are one of the two main causes of pancreatitis, the other being excessive alcohol ingestion,” Sandha notes.
At times, given the symptoms, it’s suspected that a stone is trapped in one of the ducts, even though an abdominal ultrasound doesn’t reveal it. In such a case, an ultrasound transducer is threaded down the throat with the help of an endoscope into the stomach. From there, “we get wonderful views of the bile duct,” Sandha says. If a stone is present, it’s removed using delicate endoscopic instruments.
In any of these situations, “the risks of [gallbladder-removal] surgery are heightened because the gallbladder anatomy can be very distorted and inflamed when you’re dealing with an acute presentation,” says Dr. Jeffrey Hawel, a surgeon at London Health Sciences Centre in London, Ont., who specializes in general surgery and advanced laparoscopic surgery. “That’s one of the rea- sons we recommend doing this electively, so it doesn’t become an emergency situation.”
The Operation
Surgery to remove the gallbladder (cholecystectomy) is one of the most common operations performed in Canada, and it’s now only rarely done through a major abdominal incision. Instead, while the person is under general anaesthesia, typically the surgery “is done through four very small incisions—one to put a camera in and three for instruments to remove the gallbladder,” explains Dr. Sean Bennett, an assistant professor in the Division of General Surgery at Queen’s University. The abdomen is inflated with carbon dioxide, providing the surgeon with a clearer view of the surgical field.
In most cases, people go home the same day. “I usually tell people they’ll have a few days of soreness from the incisions, and we give them some pain meds to manage that,” Bennett says. “People can get back to light cardio within a week or two.” Most surgeons recommend avoiding heavy lifting for a couple of weeks, to avoid strain that could potentially open the stitches and cause a hernia.
As with any medical intervention, there are some risks, which are relatively slight. The majority are those associated with all surgeries, such as bleeding and infection. “These are quite low,” Bennett says. “The risk of bleeding serious enough to require a transfusion, I would say, is less than one per cent, and the risk of developing a wound infection is probably two to three per cent.”
The main risk that’s specific to gallbladder removal is the possibility of injury to the common bile duct in the process of dissecting it away from the liver. This can occur “if the anatomy is confusing or because things are inflamed and stuck together,” Hawel says. The chance of this happening is in the neighbourhood of one in 400 to one in 800. “It’s quite uncommon but can be serious for that one person and can involve a pretty major operation done by a liver surgeon,” Bennett says.
Removing the gallbladder doesn’t completely eliminate the possibility of another stone forming years later. In an unlucky few, the bile duct dilates a little over time, forming a small pouch where bile can sit. “Because the biochemistry of the bile has not changed, a stone can form in the bile tube,” Sandha explains.
Waddingham is among the unfortunate: it’s happened to him twice. The second time, the problem was diagnosed more quickly because he not only recognized the symp- toms but also went to the ER with the medical records regarding his previous bile stone.
Overall, however, people can look forward to a future that’s free from frequent bouts of pain and worry over whether their next meal might trigger another painful attack.
“There are things we do surgically that are tough to recover from, but gallbladder removal is not one of them—it’s a well-tolerated surgery,” Hawel says. “Patients feel so much better afterwards—they’re happy and glad they did it.”
