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Gallstones can also be present in the common bile duct, a condition called choledocholithiasis.
 
Secondary Common Bile Duct Stones. In most cases, common bile duct stones originally form in the gallbladder and pass into the common duct (called secondary stones). Choledocholithiasis occurs in about 10% of patisents who have gallstones.

Primary Common Bile Duct Stones. In less common cases, the stones form in the common duct itself (called primary stones). Primary common duct stones are usually of the brown pigment type and are more likely to cause infection than secondary common duct stones.}

Gallbladder Diseases without Stones
Gallbladder disease can occur without stones, a condition called acalculous gallbladder disease).
[See below Gallbladder Disease without Stones.]

GALLBLADDER DISEASE WITHOUT STONES (ACALCULOUS GALLBLADDER DISEASE)

Gallbladder disease can occur without stones, a condition called acalculous gallbladder disease. It can be acute (arising suddenly, often as a one-time occurrence) or chronic (persistent):

• Acute acalculous gallbladder disease usually occurs in patients who are very ill from other disorders. In such cases, inflammation occurs in the gallbladder, usually from a diminished blood supply or an impairment in the ability of the gallbladder to contract.

• Chronic acalculous gallbladder disease (also called biliary dyskinesia) appears to be caused by muscle defects or other problems in the gallbladder that impair its ability to contract and release bile.

Diagnosing Acalculous Gallbladder Disease

Diagnosing Acute Acalculous Gallbladder Disease. Symptoms are similar to acute cholecystitis with gallstones, but they may be obscured by other medical conditions, since patients with this condition are often critically ill with other illnesses.

Diagnosing Chronic Acalculous Gallbladder Disease. Chronic acalculous gallbladder disease is usually diagnosed when a patient complains of gallbladder symptoms but there is no evidence of stones using standard imaging techniques. (More than half of patients initially diagnosed with this disease, however, are eventually shown to have small stones or gallbladder sludge.) The patient is given the hormone cholecystokinin octapeptide (CCK), which induces gallbladder contraction, followed by a radioisotope scan that determines if the gallbladder is emptying correctly. If the gallbladder demonstrates difficulty releasing bile, doctors usually consider the diagnosis confirmed.

Treatment for Acalculous Gallbladder Disease

Treatment for Acute Acalculous Gallbladder Disease. Acute acalculous gallbladder disease has a very high rate of serious complications (gangrene, perforation, and pus in the gallbladder), so emergency removal of the gallbladder is warranted.

Treatment for Chronic Acalculous Gallbladder Disease. Most patients (75% to 90%) diagnosed with chronic acalculous gallbladder disease are relieved of their symptoms by cholecystectomy (removal of the gallbladder). [See What Are the Surgical Procedures for Gallstones and Gallbladder Disease?]

WHAT ARE THE SYMPTOMS OF GALLSTONES AND GALLBLADDER DISEASE?

About 90% of gallstones provoke no symptoms at all. If they do occur, the chance of developing pain is about 2% per year for the first 10 years after stone formation, after which the chance for developing symptoms declines. On average, symptoms take about eight years to develop. The reason for the decline in incidence after 10 years is not known, although some physicians suggest that "younger," smaller stones may be more likely to cause symptoms than larger ones.

Biliary Pain
The mildest and most common symptom of gallbladder disease is intermittent pain called biliary colic, which occurs either in the mid- or the right portion of the upper abdomen. A typical attack has several features:

• The primary symptom is typically a steady gripping or gnawing pain in the upper right abdomen near the rib cage, which can be quite severe and can radiate to the upper back. Some patients with biliary colic experience the pain behind the breast bone.

• Nausea or vomiting may occur.

• Changes in position, over-the-counter pain relievers, and passage of gas do not relieve the symptoms.

• Biliary colic typically disappears after one to several hours. If it persists beyond this point then acute cholecystitis or more serious conditions may be present.

• The episodes typically occur at the same time of day but less frequently than once a week. Large or fatty meals can precipitate the pain, but it usually occurs several hours after eating and often wakes the patient during the night.

• Recurrence is common, but attacks can be years apart. In one study, for example, 30% of people who had had one or two attacks experienced no further biliary pain over the next 10 years.

Digestive complaints such as belching, feeling unduly full after meals, bloating, heartburn (burning feeling behind the breast bone), or regurgitation (acid backup in the food pipe) are not likely to be caused by gallbladder disease. Conditions that may cause these symptoms include peptic ulcer, gastroesophageal reflux disease, or indigestion of unknown cause. [For more information, see the Well-Connected Reports #19 Peptic Ulcers or #85 Gastroesophageal Reflux Disease.]

Symptoms of Acute Cholecystitis (Gallbladder Inflammation)

Inflammation and infection in the gallbladder (acute cholecystitis) are usually caused by gallstones, although sometimes they occur without stones. The symptoms in either case are similar to those of biliary colic but are more persistent and severe. They include the following:

• Severe pain and tenderness in the upper right abdomen is the most common complaint. It also may radiate to the back or may occur under the shoulder blades, behind the breast bone, or on the left side. Pain frequently occurs when drawing a breath.

• The discomfort is intense and steady and can last for days.

• About a third of patients have fever and chills.

• Nausea and vomiting may occur.

Anyone who experiences such symptoms should seek medical attention. Acute cholecystitis can progress to gangrene or perforation of the gallbladder if left untreated. (People with diabetes are at particular risk for this complication.)

Symptoms of Chronic Cholecystitis or Dysfunctional Gallbladders

Chronic gallbladder disease (chronic cholecystitis) is marked by gallstones and low-grade inflammation. In such cases the gallbladder may become scarred and stiff. Symptoms of chronic gallbladder disease include the following:

• Complaints of gas, nausea, and abdominal discomfort after meals are the most common, but they may be vague and indistinguishable from similar complaints in people without gallbladder disease.

• Chronic diarrhea (four to 10 bowel movements every day for at least three months) may be a symptom of gallbladder dysfunction.

Symptoms of Stones in the Common Bile Duct (Choledocholithiasis)

Stones lodged in the common bile duct (choledocholithiasis) can cause symptoms that are similar to those that lodge in the gallstone, although they may have the following:

• Jaundice (yellowish skin).

• Dark urine, light stools, or both.

• Heartbeat may become rapid, and blood pressure may drop abruptly.

• Fever, chills, nausea and vomiting, and severe pain in the upper right abdomen. These symptoms suggest an infection in the bile duct (called cholangitis).

As in acute cholecystitis, patients who have these symptoms should seek medical help immediately. They may require emergency treatment.

HOW SERIOUS ARE GALLSTONES AND GALLBLADDER DISEASE?

Asymptomatic gallstones seldom lead to problems. Death from even symptomatic gallstones is very rare, accounting for only 0.2% of annual deaths in the United States. Serious complications are rare and, if they occur, usually develop from stones in the bile duct or after surgery.
However, gallstones, can cause obstruction at any point along the ducts that carry bile and, in such cases, symptoms can develop.

• In most cases of obstruction, the stones block the cystic duct, which leads from the gallbladder to the common bile duct. This can cause pain, infection, and inflammation.

• About 10% of patients with symptomatic gallstones also have stones that pass into and obstruct the common bile duct (called choledocholithiasis).

Complications of Acute Cholecystitis (Gallbladder Inflammation)

The most serious complication of acute cholecystitis is infection that spreads to other parts of the body (septicemia). This can be life-threatening. Symptoms include fever, rapid heartbeat, fast breathing, and mental confusion.
Among the conditions that can lead to septicemia are the following:

• Gangrene or Abscesses. If acute cholecystitis is untreated and becomes severe, inflammation can cause abscesses or destroy enough tissue in the gallbladder (called necrosis) to lead to gangrene.

• Perforated Gallbladder. About 1% to 2% of persons with acute cholecystitis have a perforated gallbladder, which is a life-threatening condition. The risk for perforation increases with a condition called emphysematous cholecystitis, in which gas forms in the gallbladder. This condition is most common in people with diabetes.

• Empyema. Pus in the gallbladder (called empyema) occurs in 2% to 3% of patients with acute cholecystitis. Abdominal pain is usually severe and is typically present for more than seven days. The physical exam is not distinctive. The condition can be life-threatening, particularly if the infection spreads to other parts of the body.

Both perforation and empyema require prompt surgery. These complications can be avoided, however, by seeing a physician as soon as gallbladder symptoms occur.

Complications from Choledocholithiasis (Stones in the Common Bile Duct)

When gallstones lodge in the common bile duct (choledocholithiasis) instead of the gallbladder, serious complications can occur.
Infection in the Common Bile Duct (Cholangitis). Infection in the common bile duct (cholangitis) from obstruction is common and serious. Those at highest risk for a poor outlook also have one or more of the following conditions:

• Kidney failure.

• Liver abscess.

• Cirrhosis.

People older than 50 are also at higher risk.

If antibiotics are administered immediately, the infection clears up in 75% of patients. If cholangitis does not improve, the infection may spread and become life-threatening. Either surgery or a procedure known as endoscopic sphincterotomy is required to open and drain the ducts.

Pancreatitis. Choledocholithiasis is responsible for most cases of pancreatitis (inflammation of the pancreas), a condition that can be life-threatening. The pancreatic duct, which carries digestive enzymes, joins the common bile duct right before it enters the intestine. It is therefore not unusual for stones that pass through or lodge in the lower portion of the common bile duct to obstruct the pancreatic duct.