Gallstone Disease: Prevention, Diagnosis and When to See a Doctor

Gallstones are extremely common: by middle age, a sizeable minority of adults in the UK have them, most without ever knowing. When they do cause trouble, though, the pain can be severe and complications such as pancreatitis or infection are potentially serious. Athletes are generally at lower risk thanks to regular exercise, but rapid weight cuts, crash dieting and long fasting periods can tip the balance. Our editorial team explains how gallstones form, how they are diagnosed and when to seek medical help.

How gallstones form

The gallbladder is a small pouch beneath the liver that stores and concentrates bile, a fluid produced by the liver to help digest fats. After a meal, the gallbladder contracts and squeezes bile into the small intestine through the bile ducts.

Gallstones form when bile becomes unbalanced. In the UK, most stones are cholesterol stones, which develop when bile contains more cholesterol than bile salts can keep dissolved. Pigment stones, made from bilirubin, are less common and are associated with conditions such as haemolytic anaemia and liver cirrhosis.

Three factors interact: bile that is supersaturated with cholesterol, a tendency for cholesterol crystals to form, and reduced gallbladder emptying. When the gallbladder contracts infrequently — for example during prolonged fasting — bile sits longer and "sludge" and stones can develop.

Stones range from grains of sand to several centimetres in diameter. Most remain silent, but about one in five people with stones eventually develops symptoms.

Risk factors — including those relevant to athletes

Some risk factors cannot be changed: increasing age, female sex, family history and certain ethnic backgrounds. Pregnancy and oestrogen-containing medicines, including some contraceptives and hormone replacement therapy, also increase risk.

Modifiable and lifestyle factors include:

• obesity and metabolic syndrome;
• rapid weight loss, such as more than about 1.5 kg per week, very low calorie diets or bariatric surgery;
• prolonged fasting and skipping meals, which reduce gallbladder emptying;
• physical inactivity;
• diets very low in fibre and high in refined carbohydrates.

For physique athletes and weight-category sports, the rapid weight loss factor is the one to watch. Aggressive cutting phases with very low fat intake, long fasting windows and large weekly losses create exactly the conditions that encourage stone formation.

Regular physical activity, by contrast, is protective. Large cohort studies from the United States found that both men and women who were more physically active had a lower risk of symptomatic gallstone disease, independently of body weight.

Symptoms and complications

The classic symptom is biliary colic: a steady, severe pain in the upper right or centre of the abdomen, often spreading to the right shoulder blade, usually lasting from 30 minutes to several hours. It frequently follows a large or fatty meal and may wake people at night. Nausea and vomiting are common.

Complications occur when a stone causes persistent blockage or infection:

Pain from gallstones can be mistaken for indigestion, a pulled muscle or even cardiac pain. Athletes sometimes attribute it to training or supplements and delay seeking help.

Seek urgent help via NHS 111, your GP or A&E if abdominal pain lasts more than a few hours, is accompanied by fever, yellowing of the skin or eyes, dark urine, or if you feel generally very unwell.

How gallstones are diagnosed and treated

Abdominal ultrasound is the first-line test recommended by NICE guideline CG188. It is quick, painless and detects most gallbladder stones. Blood tests, including liver function tests, full blood count, CRP and amylase or lipase, help identify complications.

If a stone in the bile duct is suspected but not seen on ultrasound, magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound may be used. Stones in the bile duct can be removed by endoscopic retrograde cholangiopancreatography (ERCP).

Asymptomatic gallstones found incidentally usually need no treatment. For symptomatic gallstones, NICE recommends laparoscopic cholecystectomy — keyhole removal of the gallbladder — and advises that it be offered within a week of diagnosis for acute cholecystitis.

Most people recover from laparoscopic surgery within one to two weeks and return to full training gradually over several weeks, depending on the surgeon's advice. Life without a gallbladder is normal for the vast majority, though some notice looser stools after fatty meals at first.

Prevention in practice

The most effective preventive measures are lifestyle-based. Keep a healthy body weight, stay physically active, eat regular meals and include fibre-rich foods such as vegetables, fruit, legumes and wholegrains.

If you need to lose weight — for health or a competition — aim for gradual loss, typically around 0.5–1 kg per week, rather than crash dieting. Include some dietary fat in meals, as very low fat intake reduces gallbladder contraction. Avoid extremely long daily fasting periods during intensive cutting phases.

For people undergoing very rapid weight loss under medical supervision, such as after bariatric surgery, doctors sometimes prescribe ursodeoxycholic acid, which trials have shown reduces stone formation. This is a medical decision and not a self-help strategy.

Be aware that certain drugs, including some fibrates, octreotide and the antibiotic ceftriaxone, are associated with gallstones or biliary sludge. Anabolic steroids and other liver-stressing substances can cause cholestasis and further complicate liver and biliary health. Discuss any regular medication with your GP if you have a history of gallstones.

Editorial team's conclusions

Gallstones are common and mostly silent, but symptomatic disease can be painful and occasionally dangerous. Regular exercise and a healthy weight protect against them, while rapid weight loss, fasting and very low fat diets increase risk — a point worth remembering during aggressive cutting phases. Ultrasound is the key diagnostic test, and keyhole surgery is the standard treatment for symptomatic stones. Fever, jaundice or prolonged pain require prompt medical attention.

Related reading includes our guides to safe rates of weight loss before competitions, liver function tests in athletes, and omeprazole and other medicines for upper abdominal symptoms.

References

1. National Institute for Health and Care Excellence. Gallstone disease: diagnosis and management (CG188). London: NICE; 2014.
2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. 2016;65(1):146–181.
3. Lammert F, Gurusamy K, Ko CW, et al. Gallstones. Nat Rev Dis Primers. 2016;2:16024.
4. Leitzmann MF, Rimm EB, Willett WC, et al. Recreational physical activity and the risk of cholecystectomy in women. N Engl J Med. 1999;341(11):777–784.
5. Shiffman ML, Kaplan GD, Brinkman-Kaplan V, et al. Prophylaxis against gallstone formation with ursodeoxycholic acid in patients participating in a very-low-calorie diet program. Ann Intern Med. 1995;122(12):899–905.
6. Erlinger S. Gallstones in obesity and weight loss. Eur J Gastroenterol Hepatol. 2000;12(12):1347–1352.