Complications and presentation of gallstones
Gallstones cause different problems depending on their position in the biliary tree. The diagram below shows possible positions where the gallstone may get stuck - select them to see what problems may arise.
Stone in the outlet of the gallbladder
 | Biliary colic - presents as sudden onset of pain in the upper abdomen and back. It is due to violent contractions of the gallbladder trying to move the stone on. It may be brought on by eating fatty meals. Sweating, nausea and vomiting are commonly present. The pain may last for 2-4 hours and subsides when the stone falls back into the gallbladder or is forced into the common bile duct. |
| Mucocele - in this case the stone remains impacted in the outlet but infection does not occur. The bile in the gallbladder is absorbed but the gallbladder wall continues to make mucous - this then fills and distends the gallbladder. This causes similar, but less intense, symptoms to biliary colic. |
| Acute cholecystitis - the stone remains stuck in the gallbladder outlet. This causes chemical irritation of the gallbladder followed rapidly by infection. The pain persists, may be more localised to the right upper abdomen and may also radiate to the right shoulder. The infection causes 'flu like symptoms with fever and chills. There will be tenderness when the abdomen is pressed over the gallbladder. |
| Empyema of the gallbladder - if acute cholecystitis does not settle with antibiotics or a mucocele gets infected the gallbladder may become full of pus. This is empyema. The patient is ill with swinging fevers. An emergency operation may be needed. |
| Perforation of the gallbladder - the gallbladder may perforate at the site of stone impaction or at the area furthest from the outlet. Pus and bile may pour into the abdominal cavity or an abscess may form near the gallbladder. The patient will be very ill with severe pain and a fever. An emergency operation may be needed. |
| Jaundice - because the bile cannot drain into the gut it overspills into the bloodstream causing the patient to become jaundiced. Itching may be severe as the bile irritates the skin. Some of the bile will be passed in the urine causing the urine to become very dark in colour. After a while the patients motion will become very pale (the bile normally gives motion its colour) and may be difficult to flush away because it will contain undigested fats. |
| Cholangitis - the bile duct may become infected causing fever (rigors), pain and jaundice (Charcot's triad). This will require emergency treatment. |
Stone in the exit of the bile/pancreatic duct
| Pancreatitis - by blocking the drainage of the pancreatic duct (even for a short time) the pancreas gland may become inflamed. This causes severe abdominal and back pain with vomiting. The stone may be very small and not cause jaundice. |
| Gallstone ileus - when the stone perforates the gallbladder and forms an abscess, the abscess may perforate into the duodenum causing a communication between the gallbladder and the duodenum (a fistula). The large stone may pass through this fistula into the small intestine. Here it may cause a blockage of the small intestine. This presents with colicky abdominal pain, distension, vomiting and constipation. It requires surgical treatment. The photograph below shows the distended small bowel and the stone removed from it. |
