Most gallstones are asymptomatic, while several other conditions can masquerade as them.

General and hepatobiliary surgeon Dr Marty Smith, Director of Hepatobiliary Surgery at The Alfred Hospital, explains key differentials, how to manage incidental findings, and why surgery is first-line once symptoms appear.

Gallstones prevalence rising

The prevalence of gallstones in western populations is estimated between 15 – 30%—but appears to be increasing, Dr Smith says.

“We’re seeing them in younger patients in particular and that’s probably a result of dietary changes,” he says. With more people having ultrasounds, increased diagnosis is also contributing.

Key differentials

Many patients present with classic biliary colic, but others report non-specific symptoms like upper abdominal discomfort, nausea or dyspepsia.

It’s important to consider acid‑related diseases such as ulcers and gastritis, he says. “And it’s not unreasonable to give people a therapeutic trial of some antacid-type treatment as we’re working through this process.”

“The other differential we’re seeing more and more is fatty liver disease. And it’s not uncommon to see patients who’ve got some slightly abnormal liver function tests, have an ultrasound, and there’s stones,” Dr Smith says. “But when you pick the history apart a bit, they’ll say things like, I get pain when I sit in my car and my knees are crunched up, or if I lean on the right-hand side. You’re getting capsular compression there, squeezing on a fatty liver. And you can palpate tenderness in the liver. We’ll see it on the ultrasound as well.”

Pancreatitis should also be on the radar and should always be referred to an emergency service. “Gallstones are one of the top two causes of pancreatitis in our community, the other being alcohol. And we now know that it is safe and recommended for the patient to have their gallbladder out during an initial admission with pancreatitis,” he says.

Acute cholecystitis can at times be managed in the community with bowel rest and some antibiotics, but frequently requires surgical or emergency referral, he adds.

Investigations: what actually helps?

Imaging plays a role when history is unclear, and Dr Smith supports a low threshold for ultrasound. “It’s a reasonable thing to go to a scan if you’re uncertain with upper abdominal symptomatology,” he says.

Blood tests, while routine, are generally not helpful in diagnosing gallstone disease as many patients will have normal liver function tests, even during acute symptomatic episodes. That said, results may point to other pathology such as fatty liver or biliary obstruction, placing the symptoms in a broader context.

Managing asymptomatic gallstones

Two-thirds of patients with gallstones found incidentally will never experience symptoms and Dr Smith recommends a conservative approach in these cases.

“As far as I’m concerned, they can keep their gallstones and their gallbladder. And that would be the most common attitude that general surgeons take towards asymptomatic stones.”

While some clinicians cite an annual conversion rate of 1–2% from asymptomatic to symptomatic disease, it’s usually best to leave things alone, he explains.

“I think a suboptimal gallbladder that’s asymptomatic is better than having no gallbladder at all in terms of gastrointestinal quality of life.”

Lifestyle factors including weight gain, rapid weight loss, and high saturated fat intake increase the risk of gallstones becoming symptomatic, so it’s important to manage these. Medications that affect gastrointestinal motility, such as opioids and tricyclics, also raise this risk and should ideally be avoided if clinically appropriate, he says.

“Also in the modern context, the GLP-1 receptor antagonists are known to reduce gastrointestinal motility more broadly, but gallbladder motility specifically, and they can increase the risk of gallstones becoming symptomatic—although that risk is very subtle, and it doesn’t yet translate to this patient needing an operation.”

When to consider surgery

Surgical intervention is usually advised in patients who’ve had a single symptomatic episode, Dr Smith says.

“The rationale is that we know anyone who’s had a single episode of gallstones has roughly an 80% chance of having another episode within two years, and near 100% by five years. So it’s not a matter of if; it’s a matter of when.”

In this context, elective cholecystectomy allows patients to return to their usual activities without fearing recurrent episodes—and is associated with improved quality of life at a population level, he explains.

There are few downsides, he adds. “For most it is day stay or overnight laparoscopic surgery with complications being rare.”

Some patients experience bloating, tummy rumbles, increased frequency of bowel movements and diarrhoea for the first month or so after surgery as their body adjusts to not having a gallbladder, he says. But surveys have consistently shown that “at the six-month mark, 95% of people are eating and drinking whatever they want, with no discernible effect on their quality of life.”

Other options for managing gallstones are limited.

Ursodeoxycholic acid is occasionally used for people with complex duct stones, he says. “But we know it takes two to three years for small stones to dissolve, and then they tend to come back.”

Regimens that purportedly flush away gallstones, such as drinking large qualities of olive oil with an acidic substance like apple cider vinegar, “fall into the category of snake oil,” he adds.

“People do pass stones in their bowel motions, but they’re not their gallstones—they’re crystallised olive oil. And that’s been thoroughly disproven in major centres.”

Patients with gallstones who choose to keep their gallbladder and are planning international travel should be advised that insurance companies often class gallstones as a chronic condition (even if they are asymptomatic), and this may affect their travel cover. Some providers offer insurance specifically for gallstones.

When to refer

“If you suspect your patient has pancreatic symptoms, be that transient derangement of the liver function test or mild elevations in lipase when they’ve had some abdominal discomfort, that’s a bit of a red flag and those patients should be referred along as quickly as possible,” Dr Smith stresses.

Patients with uncontrolled pain should also be escalated promptly.

“If it gets to that point, they can come to an emergency department. And the modern way of thinking in most major centres in Australia is that we will just see the patient, assess them, and get their operation done.”

For less acute but persistent symptoms, he suggests contacting the specialist, noting assessment can often be expedited.

“I get calls from GPs quite frequently saying, this patient’s having a lot of trouble, can we see them sooner rather than later,” he says. “Even in the public sector, we often get referrals that are quite urgent and at times we’ll get them in within a week or so.”

Key takeaways

• Gallstones affect 15–30% of adults, but two‑thirds remain asymptomatic
• Important differentials include acid-related diseases, fatty liver and pancreatitis
• Ultrasound is the main investigation; blood tests are often normal even when stones are symptomatic
• Asymptomatic gallstones do not require surgery in most cases
• Recurrence rate is high after a first symptomatic episode and elective cholecystectomy is usually appropriate
• Post‑operative bowel changes are common but usually settle by six months
• Uncontrolled pain or suspected pancreatitis warrants urgent referral to an ED