Gallstones Explained: Biliary Colic, Cholecystitis, and When Surgery Is Necessary

When your right upper abdomen suddenly locks up in sharp, unrelenting pain, it’s not just indigestion. It could be a gallstone blocking the flow of bile. This isn’t rare - about 1 in 10 adults in the U.S. has gallstones. But most never know it. The real problem starts when those stones cause biliary colic - the first warning sign that something’s wrong.

What Happens During Biliary Colic?

The pain is steady, not crampy. It doesn’t come and go with gas or vomiting. It starts suddenly, peaks within an hour, and lasts 1 to 5 hours. You’ll feel it under your right ribs or in the center of your belly, sometimes radiating to your right shoulder. It’s not the kind of pain you can ignore. Most people end up in the ER because of it.

Cholesterol stones make up 80% of cases in the U.S. They form when bile has too much cholesterol and not enough bile salts. The rest are pigment stones, made of bilirubin, often linked to liver disease or blood disorders. Women are 2 to 3 times more likely to get them than men. Obesity, rapid weight loss, and being over 40 also raise your risk.

When Biliary Colic Turns Into Cholecystitis

Signs include fever, nausea, vomiting, and tenderness when you press on your upper right abdomen. The pain doesn’t go away like it does with biliary colic. It sticks around for days. About 1 in 5 people who have biliary colic will develop cholecystitis. Left untreated, it can lead to a ruptured gallbladder, abscesses, or even sepsis.

Doctors use ultrasound to confirm it. That’s the go-to test - quick, no radiation, and 95% accurate for gallstones. Blood tests might show elevated white blood cells or liver enzymes. If the stone has moved into the common bile duct, you might turn yellow (jaundice) or have dark urine - that’s choledocholithiasis. It’s serious. It can also trigger pancreatitis, which is life-threatening.

Can You Dissolve Gallstones Without Surgery?

Shock wave therapy (lithotripsy) used to be an option. It breaks stones into tiny pieces, then you take pills to dissolve them. But it’s rarely used now. Why? It’s expensive, requires multiple sessions, and the stones come back. Plus, it doesn’t work on multiple stones or larger ones.

There’s no reliable medication to prevent stones from forming. Lifestyle changes - losing weight slowly, eating regular meals, avoiding high-fat junk food - help reduce risk, but they won’t make existing stones disappear. If you’ve had even one episode of biliary colic, the odds are stacked against you. More than 90% of people will have another episode within 10 years. Two-thirds get another one within two years.

Why Surgery Is the Standard - and When It’s Best

Laparoscopic surgery means four small cuts, a camera, and tiny tools. Most people go home the same day or the next morning. Recovery? About 7 days. Compare that to open surgery - a big cut, 4 to 5 days in the hospital, and a month to feel normal again.

Studies show 95% of patients are happy with the results. Pain disappears. No more ER visits. No more anxiety before meals. A 45-year-old woman in Cleveland Clinic’s patient newsletter had 17 episodes of biliary colic over 18 months. After surgery, her pain was gone in 10 days. Back to work in two weeks.

But timing matters. If you have acute cholecystitis, the Society of American Gastrointestinal and Endoscopic Surgeons recommends surgery within 72 hours. Waiting increases the chance your surgery will need to be converted to open - from 25% down to just 7% if done early.

Who Should Avoid Surgery?

Dr. Emily Finlayson at UCSF points out that for patients over 75 with three or more chronic conditions, the 30-day death rate after surgery rises to 2.8%. That’s not a small number. In those cases, doctors may delay surgery and treat with antibiotics and pain control first. Some may never have surgery if their symptoms are mild and they’re not willing to take the risk.

There’s also a new option for high-risk patients: endoscopic ultrasound-guided gallbladder drainage. The FDA approved it in 2023. It’s not a cure - it’s a bridge. A thin tube is placed into the gallbladder to drain the infection. It buys time. It’s used when surgery is too dangerous right now. But eventually, most still need the gallbladder removed.

What to Expect After Surgery

But not everyone feels perfect. About 12% develop diarrhea after surgery. That’s because bile flows directly into the intestine instead of being stored. It’s usually temporary. A few people get what’s called post-cholecystectomy syndrome - ongoing pain, bloating, or nausea. That’s rare - about 6% - and often means another issue was missed, like a bile duct stone or a motility problem.

Some patients report feeling “off” for months. That’s often because they’re still eating the same high-fat meals they did before. Your body adapts. Give it time. Cut back on fried food, creamy sauces, and butter. Eat smaller, more frequent meals. Your digestion will adjust.

The Bigger Picture: Why This Matters

Hispanic populations have a 45% higher risk than non-Hispanic whites. Women, especially those who’ve had children, are at higher risk. Age matters. The older you are, the more likely you are to have stones - and the riskier surgery becomes.

But here’s the truth: if you’ve had biliary colic, waiting doesn’t help. The longer you wait, the more likely you are to end up in the hospital with cholecystitis. Emergency surgery is harder, riskier, and more expensive. Most people who delay surgery end up having it anyway - within 5 to 6 years.

Doctors now use ERAS protocols - Enhanced Recovery After Surgery. That means getting you moving fast, eating early, and minimizing pain meds. Hospitals using these protocols see 30% shorter hospital stays and 25% fewer readmissions.

There’s no perfect non-surgical cure. Pills don’t last. Shock waves are outdated. Drainage tubes are temporary. Surgery is the only thing that gives you back your life - without the fear of the next attack.

What to Do Next

If you’re over 75 with multiple health problems, ask about drainage as a bridge - but don’t assume you’re off the hook. You still need a plan.

And if you’ve had surgery and still have symptoms? Don’t brush it off. Go back. Something might be missed. You’re not imagining it. You’re not alone.

Gallstones aren’t glamorous. But they’re common. And they’re fixable. The sooner you act, the less pain you’ll live with - and the better your life will be after.