Gallstones(GB stone) means the occurrence of a small, gravel-like substance inside the gallbladder.

A gallbladder(cystis fellea) is formed in a small sac-shaped structure, it is located on the upper right side of the abdomen which is under the liver. Cholelithiasis is a disease that makes the fluids stored in the gallbladder hardened into a rock-like substance that is called the gallstone. In western countries 10% of the total population, and in South Korea 4% of the population suffers from gallstones.

This liquid called ‘bile’ is needed to support the digestion of fat, it is first produced in the liver then stored in the gallbladder until the body needs it. When needed, the gallbladder contracts and pushes out the bile to a tube named the common bile duct. As the bile moves to the end of the common bile duct which is connected to the small intestine, the bile is finally excreted to support the food digestion.

About 500 ~ 1,200 ml (average of 800 ml) of bile is produced in a day. Bile contains water, cholesterol, fat, bile salt, protein and bilirubin. Bile salt inside the bile resolves fat and bilirubin makes the bile and stool show a yellowish-brown color. But if the liquid bile contains too much of a cholesterol, bile salt, bilirubin it may harden into a gallstone.

According to the anatomical locations, a gallstone is sorted into two, ‘gallbladder stone’ and ‘gallbladder stone at the biliary tract’. And the gallbladder stone at the biliary tract is once again divided into two, ‘intrahepatic bile duct gallstone’ and ‘extrahepatic bile duct gallstone’. If sorted by a chemical composition, it is divided as cholesterol gallstones and pigment gallstones.

80% of all gallstones are cholesterol stones, that usually have yellow-green color and are mainly made of hardened cholesterol. And for pigment gallstone, it is a small black stone made of bilirubin. The size of the gallstone may be as small as a grain of sand, but also be big as a golf ball. There may be a single large gallstone, or a hundreds of tiny gallstones, or it may occur in the combination of these two types of gallstones stated previously, developed in the gallbladder.

If any of the gallstone that has slipped out of the gallbladder, blocks the tube that carries the bile starting from the liver to the small intestine, it may cause a blockage in the normal flow of the bile. These are some of the tubes that the bile goes through

• Ductus hepatocysticus : A passage that carries the bile out from the liver
• Cystic duct : Carries the bile within and without the gallbladder
• Common bile duct : Carries the bile starting from the cystic duct and ductus hepatocysticus, to the small intestine

When the bile is jammed in these tubes, it may lead to inflammation on the gallbladder, bile ducts and in a rare case the liver. Including the pancreatic duct that carries the digestive enzymes from the pancreas, various tubes are connected to the common bile duct. In some cases the gallstone that has passed down through the common bile duct may cause inflammation on the pancreas. This situation is referred as gallstone pancreatitis. It may lead to serious pain and potential dangerous conditions.

If any of the bile ducts are blocked for a certain time, it causes serious damage and infection to the gallbladder, liver, pancreas. By any chance left without getting medical treatment, it may lead to fatal situations. We usually diagnose the degree of the situation’s seriousness by these symptoms: fever, jaundice, constant pain.

Cholesterol gallstones occur in these situations : the bile containing too much cholesterol and bilirubin, bile containing insufficient amount of bile salt, when the gallbladder cannot fully release or sufficiently excrete produce the bile. But sadly, the accurate cause of these imbalance hasn’t been discovered yet.

Also the cause of pigmented gallstones are yet to be found too. Pigmented gallstones tend to occur on patients with these characteristics: cirrhosis on the liver, infection on the bile duct, hereditary blood disorders such as drepanocytic anemia that causes the liver to produce massive amount of bilirubin.

As for risk factors, the simple existence of gallstones may cause more of them to develop. The factors that influence the development of cholesterol gallstones in particular include these factors:

- Sex

The occurrence rate of cholelithiasis in women patients are about twice as high in men patients. Extreme estrogen because of pregnancy, hormonal imbalance caused by hormone replacement therapy, oral contraceptives makes the cholesterol levels inside the bile increase and reduces the movement of the gallbladder resulting cholelithiasis.

- Family medical history

Cholelithiasis tend to show high occurrence in families, this shows the possibility of genetic association.

- Overweight and rapid weight loss

As obesity is one of the major risk factor of cholelithiasis, cholelithiasis is particularly common in obese women patients. Results in huge clinical studies also shows that overweight too increases the risk of cholelithiasis.

If you’ve been fasting for a long-term or have experienced sudden weight loss, the body metabolizes fat. This makes the liver to make additional cholesterol secretion by the bile, causing the production of gallstone. It also interferes the gallbladder's proper excretion of the bile.

- Diet

A diet full of high-fat, high-cholesterol, and low-fiber increases the risk of cholelithiasis development by causing the increase of cholesterol levels in the bile and reducing the bile excretion from the gallbladder.

- Age

Patients over 60s, are more likely to get gallstones. It is because as humans age, they tend to secrete more cholesterol in the bile than usual.

- Cholesterol decrease drugs

Drugs that lower cholesterol levels in the blood actually Increases the amount of cholesterol excreted in bile. By this, the risk of cholelithiasis increases.

- Diabetes

Usually diabetes patients have high levels of fatty acids called the neutral fat. This may increase the risk of cholelithiasis.


There is a thing called as ‘4F’ in the cholesterol gallstone correlated factor, this is referred as Female, patient with age over Forties, Fatty, Fertile. As cholesterol gallstone has high occurrence in women than men, patients over 40 years old, obese patient, and patient with multi-parity, we call this four factors as 4F.
Patients with high risk of cholelithiasis are.

• Women, especially if she’s pregnant or dosing on an oral contraceptive pill and estrogen replacement drug.
• Patients over 60 years old.
• Patient that is obese or over-weighted
• Patients that has been fasting or experienced sudden massive weight loss.
• Patient with family medical history of cholelithiasis

The symptoms of cholelithiasis varies from no symptoms at all to stomachache, jaundice, fever. Most common symptoms from above is stomachaches and stomach cramp.

As the gallstone moves along the bile duct, it tends to cause bile duct obstruction. When this happens, the pressure inside the gallbladder increases and results in on or more symptom occurrence. The symptoms caused by blockage of the bile duct is usually called a gallbladder attack, since it happens very suddenly. Gallbladder attacks tends to appear especially after a greasy meal and during the night time. A typical gallbladder attack may cause these kind of symptoms.

If you are experiencing these kind of gallbladder attacks, go visit the hospital. These symptoms tend to occur while the gallstones move along the biliary tract. Symptoms of gallbladder attack may improve temporarily, but can also lead to bile duct obstruction. This causes infection on the gallbladder which could make the gallbladder burst.

If you are experiencing any of the symptoms stated below, you need a medical treatment from the doctor.

• Pain that lasts for 5hours
• Nausea and vomiting
• Mild or severe fever and chills
• When the skin and the white of the eye seems yellowish(jaundice)
• Gray soft stool

Although many patients have gallstones, not much do they have particular symptoms. This is referred as “asymptomatic gallstone”. These gallstones does not interfere with the functions of the gall, liver, pancreas and does not need a medical treatment. As for the case of asymptomatic gallstone, 50% of the patients live along their lives with no particular abnormal symptoms.

Cholelithiasis may be discovered while cholecystitis diagnose, but sometimes are accidentally discovered during another examinations. If a patient is suspected of cholelithiasis, we proceed an abdominal ultrasonography. Although it diagnoses more than 90% of the gallbladder gallstones, it lacks in accuracy when it comes to intrahepatic gallstones or gallstones in the bile duct.

Abdominal ultrasonography usually makes the gallstones appear white, and since it cannot pass through gallstones because of the characteristics of ultrasound, creates a dark shadow behind the gallstones. Unlike other lesions like gallbladder polyps and etc, gallstones inside the gallbladder could actually move when the patient changes one’s posture. So you may be requested to change your posture or to do breathing exercises during the examination.

CT(Computed tomography) is a non-invasive radiography that makes the cross-sectional images of the human body. This test not only shows the gallstones, but also the complications of it such as infection of the gallbladder or bile duct, and perforation.

Endoscopic retrograde cholangio pancreatography is used to diagnose and treat gallstone in the bile duct by detecting the location and removing them. Procedure : It is performed under mild anesthesia, makes the endoscope pass the throat and go through the stomach until they reach the small intestine. As the endoscope is connected to a computer, video monitor, the doctor adjusts the endoscope and obtains visual data by injecting a contrast agent in order to make the bile duct more visible at the monitor. This method helps the doctor to see the location of gallstones and bile ducts with disorders, the discovered gallstones are also removed by the devices equipped on the endoscope.

Cholescintigraphy obtains a visual data of the gallbladder by injecting a harmless amount of radioactive material to the patient. The principles of this procedure is, when this radioactive material is absorbed into the gallbladder, it stimulates the gallbladder to contract. This test is used to diagnose abnormal contractions of the gallbladder and obstruction of the bile duct.

In order to detect signs of infection, obstruction, pancreatitis, jaundice, a blood test may be proceeded.

Symptoms of cholelithiasis are : heart attack(angina), appendicitis(cecitis), stomach ulcer, irritable colon syndrome, diaphragmatic hernia, pancreatitis, hepatitis(since cholelithiasis has similar symptoms with it, accurate diagnosis is crucial).

If the incident discover of asymptomatic cholelithiasis occurred, no treatment is required. But if you’ve experienced particular symptoms because of cholelithiasis, you may consider undergoing cholecystectomy. Since the gallbladder is not an essential organ for human survival, the surgery that removes the gallbladder is one of the most common surgeries performed in adults patients.

It is still a controversial issue whether the patient needs cholecystectomy or not, when diagnosed with asymptomatic gallstone. But in the following cases, we recommend cholecystectomy to the patient.

• Patient with high risk or has suspension of gallbladder cancer
• Patients with calcification of the walls in the gallbladder or porcelain gallbladder
• Patients with gallbladder polyp bigger than 1cm accompanied with gallstone
• Patients with gallstones bigger than 3cm
• Patients with adenomyoma at the gallbladder accompanied with thickening on the gallbladder walls.
• Although the patient has gallstone on the common bile duct, but are experiencing no particular symptoms
• Patients planing on an organ transplant
• Patients with hemoclastic conditions that makes chronic blood cell break such as sickle-cell anemia

Not every patient needs cholecystotomy, but some patients show high chances of symptom occurrence in the future. So some actually consider going through surgery for the benefit of prevention purposes.

• Patients with life expectancy over 20 years has high chance of symptom occurrence in the future
• Patients with gallstone bigger than 2cm
• Diabetes patients
• Patients who have shown dysfunction on the gallbladder in gallbladder function examination
• Patients with gallstones, experiencing indigestion with no apparent cause.

The treatment depends on the location of the gallstones, it differs whether the gallstones are in the gallbladde, the liver or the extrahepatic biliary tract. Additionally the existence of symptoms and the composition of gallstones may affect the treatment plan. Also the removal method of the gallstones varies from surgically opening the stomach, to taking lithotriptic medicine, and finally removing the gallstone by endoscopy.

Almost every cholecystectomy is done by laparoscopically. After the anesthetic is injected, the doctor creates some small holes in the abdomen in order to put a laparoscope and a small video camera thought it. Then the camera inside the abdominal cavity sends an enlarged visual data to the video monitor. Now the doctor is ready to observe a close-up view of the organs and tissues. While watching the visual data, using the devices, the doctor carefully separates the gallbladder from the liver, bile ducts and other structures. Then cuts the cystic duct and removes the gallbladder through one of the small holes priorly made on the abdomen.

Usually one night of hospitalization is enough for the recovery after laparoscopic cholecystectomy. The patient may resume normal activities at home after resting for a few days. Since the laparoscopic surgery does not cut the abdominal muscle layer, it has less pain andcomplications compared to laparotomy which needs 10-20cm of incision in the abdomen.

But if a severe inflammation of the gallbladder shows during the screening which means that the gallbladder was infected or you’ve experienced injury by any other surgeries, you might have to receive a laparotomy. Some patients goes through laparotomy when the doctor discovers some problems during the laparoscopic operation, and needs a bigger incision site than now. To recover from a laparotomy, it may take 3-5 days of hospitalization and weeks staying home. Laparotomy takes about 5% of the total gallbladder surgery.

The most common complications of gallbladder surgery are damage on the bile ducts. Damage on the bile duct may lead to bile leakage to the damaged common bile duct, cause pain, and also has the possibilities of dangerous infections occuring. Small damages could sometimes be treated by non-surgical treatments, but for the case of a big damage, it has a bit more serious condition and may require additional surgery.

If the gallstones are existing inside of the bile duct, the location of the gallstones may be found by retrograde cholangio pancreatography before or during the gallbladder surgery and removed through endoscopy at the same time. Some of the patients who have received cholecystectomy may get diagnosed in gallstones in the bile ducts after weeks, months, or even years after the surgery. In this cases, the gallstone is successfully removed by endoscopic retrograde cholangio pancreatography and endoscopic cholelithotomy.

For drug treatment in treating gallstones, the Ursodiol(brand of the name: Urusa) a component derived from bile acids are medicated. We give this treatment a try when the gallstone’s main component are cholesterol gallstones, the patient only have mild symptoms like digestive disorders or epigastric discomfort, the sized of the gallstone is less than 1.0cm. There may be some side effects such as mild diarrhea, abdominal pain, and biliousness.

This experimental medical treatment skills are proceeded by directly injecting the medication into the gallbladder to dissolve cholesterol gallstones. Although this may dissolve a few of the gallstones within a few days, it is also reported that it leads to irritation and complications. It is a skill usually considered in patients that has small gallstones accompanied with symptoms.

- Acute cholecystitis

About 10% of the patients with symptomatic cholelithiasis experience acute cholecystitis. It is caused by the complete obstruction on the cystic duct. If the acute cholecystitis is late-diagnosed, it may lead to gangrenous cholecystitis, gallbladder perforation, biliary peritonitis. So the diagnosis of the acute cholecystitis should be proceeded through clinical suspicion and diagnostic imaging(a high-sensitivity test such as ultrasonography and gallbladder scintigraphy).

In the past, early surgery for acute cholecystitis was not recommended that much. Because of that, many patients received treatment with jugular vein IV, antibiotics, pain killers until the inflammation of the gallbladder was healed. Then selectively considered on undergoing cholecystectomy(late-cholecystectomy). But sadly, more than 20% of patients shown no response from this medical treatment or experienced recurrence of cholecystitis during the treatment. Studies that compared early cholecystectomy with late-cholecystectomy, about whether the early cholecystectomy could improve the treatment outcome of acute cholecystitis, has shown that early cholecystectomy could shorten the total hospitalization period than the late-cholecystectomy but could not reduce the overall complication rate. Based on these study results, when diagnosed as acute cholecystitis a patient should receive treatment with jugular vein IVs and undergo cholecystectomy as early as possible while solving the accompanied medical problems.

If the patient with acute cholecystitis is going through a very bad body condition or in high risk by other followed surgeries, the patient should priorly receive medical management with IVs, antibiotics, pain killers. When these treatments stated above have failed, ‘Percutaneous gallbladder drainage’ should be considered. 80% of patients who received this procedure shows clinical improvement within 5 days after the procedure.

- Choledocholithiasis

Gallstones can move from the place of formation inside the gallbladder, and travel through the cystic duct and arrive at the common bile duct. About 15% of patients accompany gallstones in the gallbladder with choledocholithiasis. Many of the common bile duct gallstones(73%) are spontaneously discharged to the duodenum with no particular problems. Patients with choledocholithiasis may be accompanied with gall pain, cholecystitis or pancreatitis and experience expansion on the bile ducts and elevation of liver functional test rates at the same time.

The essential factor in the treatment of choledocholithiasis is the removal of gallbladder and the remaining choledocholithiasis. There are two surgical treatments in the treatment of choledocholithiasis. One is to perform cholecystectomy and removal of the choledocholithiasis at the same time using the laparoscopy, and the other is to first remove choledocholithiasis through endoscopic retrograde cholangio pancreatography before the surgery and then perform laparoscopic cholecystectomy. Although both of these methods have shown same effects on the removal of choledocholithiasis, the former that uses the laparoscopy could shorten the hospitalization period in an average of 3 days.

- Gallstone pancreatitis

As the gallstones travels down along the common bile duct, it may temporarily be jammed at the duodenum’s papilla and cause acute pancreatitis. Once a gallstone pancreatitis occurs, the recurrence rates are very common. 61% of the patients discharged without receiving cholecystectomy are re-hospitalized for recurrent pancreatitis. When compared to gallstone pancreatitis patients who received cholecystectomy on their first hospitalization and patients who did not, patients that have received cholecystectomy after the recurrent gallstone pancreatitis occurred has reported a longer hospitalization period and a bit more on the complications occurrence too(pneumonia, wound infection, cardiac infarction). So for now, cholecystectomy is recommended during the hospitalization period for gallstone pancreatitis. But for patients with very severe the gallstone pancreatitis, too early perform of the cholecystectomy may lead to poor prognosis. Because of this, the International Pancreatic Society recommended to wait for clinical recovery and improvement of pancreatitis before considering biliary tract surgery. Recently the studies about the role of endoscopic retrograde cholangiopancreatography (ERCP) are being proceeded. Compared to a conservative treatment in another recent study, patient that have received ERCP within 72 hours has shown statistically significant number, no reduction in overall complications and mortality. Therefore not every gallstone pancreatitis patient should receive ERCP for now, but it is true that it is effective on patients with obstructive jaundice and cholestasis.

Luckily, the gallbladder is not an essential organ for the human survival. The liver makes plenty amount of bile that is needed to digest a normal meal. But if the gallbladder is removed, instead of the bile being stored in the gallbladder, it is excreted from the liver directly goes to the small intestine through the liver biliary duct and common bile duct. This makes the bile’s movement to the small intestine more frequent. Because of this, 1% of the patients may have symptoms like more frequent and soft bowel movements. Although these changes are usually temporary, if persists, please consult with a doctor.

Even if you don’t have a gallbladder, a gallstones may develop in the bile ducts which is the passage that makes biles moves downwards. If this occasion occurs, it becomes the 1% cause of the recurrence of bile duct stones in patients who have received cholecystectomy.

Just because one ate some anchovies, spinach, or calcium supplements, does not leads to ouccrence of gallstones. So please do not avoid intaking calcium supplements for osteoporosis prevention or calcium-rich foods because of this belief.

There are no particular food that is known as good for preventing gallstones after cholecystectomy. But avoiding greasy food and eating evenly foods with no overeating, may help preventing gallstone occurrence. It is also a big help at preventing gallstones if you are not obese and keep the appropriate exercise going on.

Unlike urinary stones, gallstones don’t tend to come out(or disappear) because the patient drank a lot of water. Cholelithiasis is different from urolithiasis, which creates stones in the kidney and urethra.

If you are a patient with gallstones but have a normally functioning gallbladder and experiencing no symptoms, no surgical treatment is necessary. Just visit the hospital for observation using regular abdominal ultrasound at once a year.

For the case of gallstones in the gallbladder, when the gallbladder wall becomes calcified, this increases the risk of gallbladder cancer. Or if you leave a giant gallstone larger than 2.5-3cm untreated for a long time, it may also increase the risk of gallbladder cancer. However, this does not means that all gallbladder stones eventually leads to cancer, it only happens in some cases. Therefore, please do not remove the gallbladder unconditionally just because you are afraid of getting cancer. If you’re a patient with asymptomatic cholecystolithiasis, it is smart to determine the treatment based on the pros and cons. But on the other hand, among cholecystolithiasis, patients with intrahepatic gallstones have a 4 times higher risk of the possible occurrence of cholangiocarcinoma than the non-patients. And unlike the gallstones in the gallbladder, gallstones in the biliary tract has short bearing period being an asymptomatic gallstone. Once the symptoms occur, in most cases, patients suffer from severe symptoms. So even if the patient doesn’t have any symptoms occurred, it is a principle to remove it as soon as it is discovered. In summary, yes there are cases of cholelithiasis progressing into cancer, but this is only in some special occasions. So it is important to consult with a specialist about which case of gallstones you have. Consequently, if you are not applied in one of the cases described above, receiving abdominal ultrasonography once or twice a year is good enough.

The purpose of diet therapy in cholelithiasis is to prevent these 3 things: production of gallstones, pain attacks that may occur in cholelithiasis, and recurrence of cholelithiasis after receiving related treatments.

Instead of westernized dietary, a Korean styled dietary that evenly eats rice and 3-4 types of side dishes at every meal, is helpful to your health. Well even if the content of the meal is good, overeating is also the cause of cholelithiasis. So it is best if you eat the right amount of food adequate for your body type or eating regularly without skipping meals. Since the standard of living arose, people tend to eat outdoors a lot. This naturally leads to frequent intake of greasy and low-fiber foods, which can also be the cause of cholelithiasis. Therefore it is necessary to choose a menu that provides a balanced diet even when you eat outside. Reducing intake in foods with high cholesterol content is also helpful, these are some foods that has high cholesterol content: egg yolks, squid, shrimp, intestines, eel, etc.

The diet therapy stated above is only applied with cholesterol gallstones patients, when the case of pigment gallstones patients, do not avoid food in particular and moderate intake of meat is also recommended. But why? The reason is that, some of the research results says not enough protein intake may show high occurrence intrahepatic gallstones too.

If you’re already going through cholelithiasis treatments, a dietary therapy that limits the fat intake and eating appropriate amount of protein, vitamins, minerals is needed. So it is important to follow these following principles. Regardless of the gallstone component(or type) the following dietary therapy is to prevent possible stomach pain from every gallstone patients.

When the symptoms of cholelithiasis are acute and has severe pain or jaundice after the surgery, a strict limitation of fat intake should be proceeded. Avoid using fat(oil, butter, margarine, mayonnaise, salad dressing, etc.) when cooking. When it comes to fish, pick ones with low-fat(frozen pollack, croaker, cod, pomfret, lean meat, etc) and limit daily intake amount less than 150g. If you excessively reduce the amount of fat intake for a long time, this could rather make harmful effects on health. So when symptoms improve, it is recommended to intake a moderate amount of oil(15g per day) when cooking and increase fish and meat intake to 200-250g per day. Vegetables and fruits does not affect on the aggravation of symptoms. Eat regularly and avoid heavy drinking, overeating, pungent food(alcohol, caffeinated drinks, soft drink, etc).

If you’re a pregnant women with symptomatic cholelithiasis, medical management with jugular vein IVs and pain killers may reduce biliary tract related symptoms. Although there is a research about a pregnant patient who received cholecystectomyduring pregnancy by other methods that has a positive result about both mother and fetus, still there are no studies comparing the performance of early cholecystectomy and medical management to a pregnant patient. So in general, for surgical treatment in pregnant patients, are proceed when the patient is experiencing recurrent cholelithiasis, shows no response after medical management but has constant pain on the biliary tract, complications related to cholelithiasis. The surgery is mostly proceeded at periods that avoids early and late stages of pregnancy.

A liver cirrhosis patient with asymptomatic cholelithiasis should be monitored with care. When compensatory liver cirrhosis patients show symptoms caused by cholelithiasis, they should consider receiving a cholecystectomy. Even at studies that have compared results of cholecystectomy that were performed in both patients with or without liver cirrhosis, liver cirrhosis patients did not show difference in mortality. But yes, liver cirrhosis patients has a higher occurrence of overall complications such as hepatorrhagia, and ascites. There is a study about cholecystectomy performed on patients with decompensated cirrhosis, although the results are significant, it has reported high mortality rates. So it is general to provide decompensated cirrhosis patients with symptomatic cholelithiasis more conservative treatment, and these treatments should be done in the purpose of improvement in the liver function before the cholecystectomy.