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Health condition · Clinically reviewed

Gallstones, biliary colic, keyhole surgery and when ERCP is needed.

Common, usually silent, occasionally serious. A clear UK pathway from first episode of pain to a settled plan, keyhole surgery or ERCP where needed.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE CG188, NICE NG104 and peer-reviewed surgical and gastroenterology sources.

  • 03

    Current for 2026

    Reflects modern UK guidance including early laparoscopic cholecystectomy and ERCP for common bile duct stones.

Key facts

Gallstones at a glance.

The essentials, in plain English: what they are, who gets them, and when they need treating.

  • What it is

    Cholelithiasis, hardened deposits of bile that form in the gallbladder, ranging from tiny crystals to stones several centimetres across.

  • How common

    Very common in the UK, affecting roughly 10 to 20 per cent of adults, with prevalence rising with age.

  • Types

    Cholesterol stones (around 80 per cent), pigment stones (black and brown) and mixed stones, each with different risk factors.

  • Silent stones

    About 80 per cent of gallstones cause no symptoms and are found incidentally on imaging.

  • Classic risk factors

    The 5 Fs, fat, female, fertile, forty and family, alongside rapid weight loss, diabetes and dyslipidaemia.

  • Definitive treatment

    Laparoscopic cholecystectomy is the mainstay for symptomatic disease, with ERCP for stones in the common bile duct.

Why this guide matters

A pathway, not a panic.

Gallstones sit on a wide spectrum, from silent findings to life-threatening cholangitis. The three anchors below shape everything else on this page.

  • Silent stones stay silent

    Most gallstones never cause trouble. Incidental findings on ultrasound rarely need treatment on their own.

  • Symptoms mean surgery

    Once biliary colic or cholecystitis has occurred, laparoscopic cholecystectomy stops the cycle for good.

  • Duct stones need ERCP

    A stone stuck in the bile duct changes the plan, adding endoscopic drainage before or around gallbladder surgery.

How the diagnosis is made

From first episode of pain to a clear plan.

The steps a UK GP, surgeon or gastroenterologist will normally follow, in order, so you know what to expect and why.

  1. 01

    Assessing

    History and risk factors

    Character of pain, relation to fatty meals, radiation to the right scapula, previous episodes and family history.

  2. 02

    Assessing

    Examination and Murphy’s sign

    Right-upper-quadrant tenderness, guarding and a positive Murphy’s sign point towards acute cholecystitis.

  3. 03

    Assessing

    Bloods and inflammatory markers

    FBC, CRP, LFTs (ALT, ALP, bilirubin) and amylase or lipase to screen for cholangitis and gallstone pancreatitis.

  4. 04

    Confirming

    Abdominal ultrasound first

    The first-line NICE-recommended test, showing stones, gallbladder wall thickness, pericholecystic fluid and bile duct dilation.

  5. 05

    Confirming

    MRCP for bile duct stones

    Magnetic resonance cholangiopancreatography is used when common bile duct stones are suspected but not confirmed on ultrasound.

  6. 06

    Planning

    Endoscopic ultrasound (selective)

    A specialist tool for small distal common bile duct stones, borderline MRCP findings and pancreatico-biliary planning.

  7. 07

    Planning

    Surgical and gastroenterology review

    Joint input decides between cholecystectomy, ERCP or a one-stage laparoscopic bile duct exploration.

Typical timeline: a first attack to a settled plan in weeks, not months.

Symptoms

What gallstone disease actually looks like.

Everything from mild biliary colic to full-blown cholangitis, plus the features that mean a stone has moved somewhere it shouldn’t.

  • Biliary colic

    Severe, colicky right-upper-quadrant or epigastric pain radiating to the right scapula, often after a fatty meal, lasting a few hours then settling.

  • Acute cholecystitis

    Persistent pain with fever, a positive Murphy’s sign and a systemic inflammatory response from an infected obstructed gallbladder.

  • Obstructive jaundice

    A stone in the common bile duct causes pale stools, dark urine, yellow skin and eyes and intense itch (pruritus).

  • Acute cholangitis

    Charcot triad of fever, jaundice and right-upper-quadrant pain, an emergency needing urgent biliary drainage.

  • Gallstone pancreatitis

    A stone passing through the ampulla can trigger acute pancreatitis with severe epigastric pain radiating to the back.

  • Mirizzi syndrome

    A stone impacted in Hartmann’s pouch compresses the common hepatic duct, mimicking a hilar obstruction.

  • Gallstone ileus

    A large stone erodes into the bowel and lodges in the ileum, causing mechanical small-bowel obstruction, mostly in older adults.

  • Red flags for emergency care

    Fever with jaundice, confusion, low blood pressure, severe back-radiating pain or persistent vomiting need same-day hospital assessment.

Treatment

How gallstones are treated in the UK.

Watch and wait for silent stones, laparoscopic cholecystectomy for symptomatic disease and ERCP for stones in the common bile duct.

  • Watchful waiting (asymptomatic)

    Silent stones found incidentally usually need no treatment, with rare exceptions such as porcelain gallbladder, large stones, haemolytic anaemia or immunocompromise.

  • Laparoscopic cholecystectomy

    The definitive treatment for symptomatic gallstones, offered within 6 weeks of a diagnosis of biliary colic under NICE CG188.

  • Early cholecystectomy for cholecystitis

    IV antibiotics, fluids and analgesia are followed by early keyhole gallbladder removal within a week, supported by the CHOCOLATE trial.

  • ERCP with sphincterotomy

    Endoscopic retrograde cholangiopancreatography clears stones from the common bile duct with a small cut in the sphincter of Oddi.

  • Laparoscopic bile duct exploration

    A one-stage keyhole alternative to ERCP that removes gallbladder and duct stones in the same operation, in selected specialist centres.

  • Emergency care for cholangitis

    Broad-spectrum antibiotics, resuscitation and urgent biliary decompression by ERCP or percutaneous drainage save lives.

  • Percutaneous cholecystostomy

    A drain placed through the skin into the gallbladder is a selective option for frail or unfit patients not suitable for surgery.

  • Dietary and lifestyle measures

    Reducing dietary fat, gradual weight loss and treating metabolic risk factors help symptoms and reduce future events.

What this guide is based on

The sources behind every claim on this page.

UK national guidance, specialist society standards and landmark trials, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP, surgeon or gastroenterologist knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • NICE. Gallstone disease: diagnosis and management (CG188).

  • NICE. Pancreatitis (NG104).

  • British Society of Gastroenterology. Guidelines on the management of common bile duct stones.

  • CHOCOLATE trial (BMJ 2018). Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high-risk patients.

Red flags

When gallstones become an emergency.

Most gallstone disease is safely managed on a planned pathway. These are the situations that need urgent hospital care instead.

  • Acute cholangitis

    Fever, jaundice and right-upper-quadrant pain (Charcot triad) suggest an infected obstructed bile duct, needing emergency antibiotics and ERCP.

  • Reynolds pentad

    Charcot triad plus shock and confusion signals septic cholangitis and organ dysfunction, a life-threatening emergency.

  • Severe gallstone pancreatitis

    Severe epigastric pain radiating to the back with vomiting and a raised amylase or lipase needs urgent hospital assessment and possible urgent ERCP.

  • Gallstone ileus

    Colicky pain, vomiting and abdominal distension in an older adult with a known history of gallstones raises concern for mechanical obstruction.

  • Emphysematous cholecystitis

    A rare gas-forming gallbladder infection, more common in diabetes, that can perforate and needs urgent surgery.

  • Gallbladder perforation

    Sudden worsening pain, generalised peritonitis and systemic collapse in acute cholecystitis is a surgical emergency.

  • Post-cholecystectomy jaundice

    Jaundice, itch or ongoing right-upper-quadrant pain after gallbladder surgery warrants urgent surgical review for a retained stone or bile leak.

  • Suspicion of gallbladder cancer

    A gallbladder mass, focal wall thickening or persistent porcelain gallbladder on imaging needs specialist assessment (see /conditions/gallbladder-cancer/).

  • Pregnancy with severe symptoms

    Symptomatic gallstones in pregnancy need obstetric-surgical joint care, with second-trimester laparoscopy sometimes considered.

Living with it

A treatable condition, with a clear ladder.

Four things that make the biggest difference day to day: what you eat, how quickly you lose weight, planning around surgery and knowing when to escalate.

A quiet reminder

Definitive treatment stops repeat attacks.

If biliary colic keeps returning, keyhole surgery usually gives complete relief and prevents the more serious complications.

  1. 01 Diet

    Ease off the fatty foods

    Large fatty meals are a classic trigger for biliary colic. Smaller, lower-fat meals are usually much better tolerated.

  2. 02 Weight

    Lose weight slowly

    Gradual weight loss lowers cholesterol saturation of bile. Very rapid loss actually increases stone formation, so aim for steady change.

  3. 03 Surgery

    Recovery is quicker than you think

    Most people go home the same day or the day after a keyhole cholecystectomy and are back to normal life within 2 weeks.

  4. 04 Escalate

    Don’t sit on jaundice or fevers

    Yellow skin or eyes, dark urine, pale stools or rigors with abdominal pain need same-day medical review, not a wait-and-see approach.

Frequently asked

Everything we get asked about gallstones.

Quick answers on causes, tests, keyhole surgery, ERCP and life after the gallbladder.

  • What are gallstones?

    Gallstones are hardened deposits of bile that form in the gallbladder, a small pouch under the liver that stores bile. Most are made of cholesterol, though pigment and mixed stones also occur. They can range from tiny crystals to stones several centimetres across.

  • What are the classic risk factors?

    The traditional 5 Fs are fat, female, fertile, forty and family history. Other important risks include rapid weight loss, obesity, type 2 diabetes, dyslipidaemia, certain medications, haemolytic anaemia and prolonged fasting or parenteral nutrition.

  • Do all gallstones need treatment?

    No. Around 80 per cent of gallstones are silent and cause no symptoms. NICE recommends leaving asymptomatic stones alone unless there is a specific reason such as porcelain gallbladder, very large stones, haemolytic anaemia or immunocompromise, when specialist advice is needed.

  • What is biliary colic and how is it treated?

    Biliary colic is severe right-upper-quadrant or epigastric pain, often radiating to the right scapula, triggered by a fatty meal and lasting several hours. NICE recommends laparoscopic cholecystectomy within 6 weeks of diagnosis to prevent recurrent attacks and complications.

  • What is the difference between cholecystitis and cholangitis?

    Acute cholecystitis is inflammation and infection of the gallbladder itself, usually from a stone stuck in the cystic duct, and is managed with antibiotics, fluids and early keyhole gallbladder removal. Acute cholangitis is infection of the whole biliary tree from a stone stuck in the common bile duct, and is a life-threatening emergency needing urgent ERCP for drainage.

  • What is ERCP and when is it used?

    Endoscopic retrograde cholangiopancreatography passes an endoscope into the duodenum, cannulates the bile duct and allows a small sphincterotomy to remove stones lodged in the common bile duct. It is used for suspected bile duct stones, obstructive jaundice, cholangitis and severe gallstone pancreatitis, and is carried out by specialist gastroenterologists (see /treatments/ercp-endoscopic-retrograde-cholangiopancreatography/).

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