Gallstones: when they can wait, and when the gallbladder should come out

Gallstones have a habit of turning up uninvited — on an ultrasound done for something else, on a health screening package, on a CT scan after an accident. That makes “I have gallstones — do I need surgery?” one of the commonest questions in my clinic. The honest answer depends far less on the stones than on what they are doing.

Silent stones can usually be left alone

The gallbladder is a small pouch under the liver that stores bile, the digestive fluid that helps you absorb fat. Stones form when the chemistry of bile falls out of balance, and they become more common with age.

The key fact: most people with gallstones never develop symptoms. Long-term studies of people with silent, incidentally found stones show that the majority stay trouble-free for years. So stones discovered by accident in someone with no symptoms generally need no operation — observation is a perfectly respectable plan. A few exceptions, such as certain gallbladder wall changes or polyps seen on the same scan, deserve an individual discussion, but they are the minority.

The symptoms that change the calculus

• Biliary colic — the classic attack: a steady, often severe pain in the upper right or central upper abdomen, frequently an hour or so after a rich or oily meal, lasting from half an hour to a few hours, sometimes radiating to the right shoulder blade. It is the gallbladder squeezing against a blocked outlet.
• Acute cholecystitis — a stone stays impacted and the gallbladder becomes inflamed: pain that persists beyond a few hours, fever, and tenderness. This usually means hospital admission.
• Jaundice — a stone escapes into the main bile duct and blocks it: yellowing of the eyes and skin, dark urine, pale stools, itching.
• Pancreatitis — a migrating stone blocks the outlet of the pancreas as well. Gallstone pancreatitis ranges from mild to life-threatening, and it always changes the management plan.

Any one of these moves the conversation from “if” to “when”.

Why symptomatic stones generally mean surgery, not waiting

Once a gallstone has caused one attack, further attacks become likely, and each carries a chance of tipping into cholecystitis, jaundice or pancreatitis. Waiting means betting that the complication will arrive at a convenient moment — and gallbladder surgery in the middle of an acute inflammation is a harder, riskier operation than the same surgery done electively in a well patient. That is the core of my advice: once stones are symptomatic, a planned operation is generally wiser than an unplanned one.

There is also no reliable non-surgical fix. Stone-dissolving medication works slowly, suits only certain stones, and the stones tend to re-form once it stops. Because the gallbladder itself is where the stones are manufactured, any treatment that removes the stones but keeps the gallbladder rarely settles the problem for good.

One caveat I always check first: not every upper abdominal pain is gallstones. Gastritis and ulcers can mimic biliary pain closely, which is why the work-up sometimes includes a gastroscopy — operating on stones that were innocent bystanders helps nobody.

What keyhole gallbladder removal involves

The operation for symptomatic gallstones is laparoscopic cholecystectomy — removal of the whole gallbladder, stones and all, through a few small incisions using a camera. It is done under general anaesthesia, typically takes around an hour, and in suitable patients is done as day surgery or with a single overnight stay. It sits within my general surgical practice alongside hernia and other abdominal work.

Recovery is usually measured in days rather than weeks: most patients are walking the same day and back to desk-based work within a week or two, with heavier activity guided over the following weeks. Occasionally — and I say this beforehand, not afterwards — safety requires converting a keyhole operation to an open one through a larger incision. That is a judgement made during surgery, in the patient’s interest.

Living without a gallbladder

The liver keeps making bile; after the gallbladder is removed, bile simply flows directly into the intestine instead of being stored first. Digestion carries on. Some people notice looser or more frequent stools in the early weeks, which typically settles, and most return to a normal diet. A sensible approach is to reintroduce rich food gradually and let comfort set the pace.

When to seek help urgently

Upper abdominal pain that lasts beyond a few hours, pain accompanied by fever or persistent vomiting, yellowing of the eyes or skin, or dark urine with pale stools — these belong in a hospital the same day, not on a waiting list. And if you have known gallstones and the attacks keep returning, the right moment for a planned operation is before the complication, not after it.