Gallstones are often picked up incidentally during routine imaging, even in people who feel completely well. The presence of these ‘silent’ gallstones can be unexpected, and it isn’t always clear whether they require intervention or can simply be monitored.

As Dr Rowcroft, Hepatobiliary Surgeon explains, gallstones are a very common finding on abdominal imaging, whether on ultrasound, CT, or MRI. What guides management isn’t the presence of gallstones alone, but whether they’re causing symptoms.

When symptoms do occur, they’re typically described as pain on the right side of the abdomen, just beneath the ribcage. This pain may worsen after meals or at night and can radiate to the right side of the back. In some cases, the presentation is less typical, with symptoms such as nausea or indigestion-like discomfort, which can make the underlying cause less obvious.

In the absence of symptoms, ‘silent’ gallstones can be safely monitored. Many people live with gallstones for years without ever noticing them, and in these cases, surgery isn’t required. Intervention is generally considered only when symptoms develop or begin affecting daily life.

However, there are certain situations where silent gallstones may warrant closer consideration even without symptoms. According to Dr Rowcroft, gallstones occurring alongside other gallbladder conditions, such as gall bladder polyps, may sometimes be considered for surgery. In addition, patients from regions where gall bladder cancer is more common, including parts of India, may also wish to discuss preventive gall bladder removal with a specialist.

Because these situations can vary depending on individual risk factors and imaging findings, patients are best advised to have a discussion with a Hepatobiliary Surgeon before deciding whether surgery is necessary.

Gallstones are often associated with diet, which leads to a common misconception that they’re caused solely by eating high-fat foods, and that switching to a low-fat diet will reliably relieve symptoms. In reality, the relationship is less straightforward.

Several factors contribute to gallstone formation, including age, gender, genetics, and pregnancy status. Many people who develop gallstones already follow a healthy diet, which means dietary habits alone don’t explain why they occur.

Diet can influence symptoms, but it doesn’t affect everyone in the same way. Some patients continue to experience significant discomfort despite following a low-fat diet, particularly when gallstones are already present. In these situations, dietary adjustment may offer partial relief, but it doesn’t address the underlying issue.

For patients with ongoing symptoms, surgical removal of the gallbladder remains the most definitive treatment. However, misunderstanding the role of diet can lead some individuals to delay surgery, hoping that stricter dietary control will resolve the problem. This can result in prolonged or recurring pain, and in some cases, worsening symptoms over time.

A low-fat diet can still be helpful in managing symptoms for certain individuals, but it isn’t a long-term solution for everyone with gallstones, nor does it replace the need for further evaluation when symptoms persist.

Because gallstone symptoms aren’t always obvious, many people initially mistake them for more general digestive discomfort. Gallstone-related pain typically develops on the right side of the abdomen beneath the ribs and commonly occurs after eating. The discomfort may last from several minutes to several hours and can sometimes feel “band-like” across the upper abdomen or radiate toward the lower part of the right shoulder blade.

Other symptoms that may occur alongside gallstones include nausea, vomiting, and fever, particularly when inflammation or infection develops.

Cholesterol gallstones are the most common type, and their formation comes down to an imbalance in the normal composition of bile. As Dr Rowcroft explains, bile functions like a detergent in the intestines, helping to emulsify and digest fat.

Bile is made up of water, cholesterol, bile salts, phospholipids, bile pigments, and electrolytes. Under normal conditions, bile salts and phospholipids help keep cholesterol dissolved. When this balance is disrupted, cholesterol can begin separating out of the bile.

Factors that increase cholesterol secretion by the liver, including pregnancy, rapid weight loss, and obesity, can raise the concentration of cholesterol within bile. At the same time, the gallbladder naturally removes water from bile, making it more concentrated. This creates a state where cholesterol becomes ‘super-saturated’, allowing it to precipitate into solid crystals.

Over time, these crystals coalesce and gradually grow into gallstones.

Rapid weight loss, in particular, is a well-recognised risk factor for gallstones, although the exact mechanism isn’t fully understood. Dr Rowcroft notes that this is likely related to increased cholesterol excretion into bile during weight loss, combined with reduced contraction of the gallbladder when individuals follow very low-fat diets.

For this reason, weight reduction is generally safest when approached gradually and with guidance from a primary healthcare provider. Crash dieting and very-low-calorie diets (VLCDs) may not produce sustainable long-term weight loss and can sometimes contribute to short-term complications, including gallstones.

Gallstones don’t always present with clear or typical symptoms, which means some people live with vague digestive discomfort for years before a diagnosis is made. The challenge is knowing which signs can be monitored, and which should prompt further evaluation.

When pain is suspected to be related to gallstones, it’s important to seek review by a primary care practitioner. Initial assessment usually includes blood tests to check liver function and an ultrasound, which is non-invasive and the most appropriate first-line test to evaluate the liver, gallbladder, and bile duct. The bile duct acts as the body’s ‘plumbing’, carrying bile from the liver to the gallbladder and into the small intestine. Depending on the findings, further evaluation by a specialist may be recommended.

Some symptoms, however, shouldn’t be ignored. Gallstones can lead to complications that cause significant pain and systemic illness. One such condition is cholecystitis, where the gallbladder becomes inflamed or infected. Another is cholangitis, which occurs when a stone blocks the bile duct and leads to a severe infection.

Red flag symptoms include:

• Persistent or constant pain lasting more than a few hours
• Fever
• Jaundice, which may appear as yellowing of the skin and eyes, often accompanied by dark urine (brown, like weak tea or beer) and pale or clay-coloured stools

The presence of these symptoms warrants urgent medical attention.

Over time, chronic inflammation from gallstones can lead to less common but more serious complications, including erosion of gallstones into the small intestine and, rarely, gallbladder cancer. While these outcomes are uncommon, they become more relevant in people with long-standing symptoms.

If symptoms have been present for some time and are accompanied by new changes such as unintentional weight loss, reduced appetite, nausea, abdominal distension, or jaundice, medical evaluation shouldn’t be delayed.

For those who have had their gallbladder removed, the long-term outlook is generally positive. As Dr Rowcroft notes, many patients find they’re able to eat a much wider variety of foods after surgery, without the concern of triggering severe pain.

A balanced diet, with an emphasis on fresh vegetables and fibre, remains the foundation of good digestive health. Most people adjust well over time, but some differences can persist.

Up to one in ten patients report that very fatty or rich foods may still trigger symptoms such as abdominal cramps, indigestion, or diarrhoea. In these cases, it becomes important to pay attention to individual triggers and adjust food choices accordingly.

A smaller group of patients may experience persistent diarrhoea due to excess bile acids in the intestine following surgery, a condition known as bile acid diarrhoea (BAD). This occurs because bile flows more continuously into the intestine without the gallbladder acting as a reservoir.

When this happens, symptoms can be managed with medications that bind excess bile acids, such as Cholestyramine. These treatments are typically prescribed by a primary care practitioner, surgeon, or gastroenterologist.