Gallstones (Cholelithiasis)

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Lee Surgery and Endoscopy was founded by Dr. Lee Chin Li, with the mission to deliver accessible and quality healthcare to our patients. We are committed to ensuring your comfort from consultation to procedures.

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Gallstones are hardened deposits that form in the gallbladder, often blocking bile flow and causing pain or digestive discomfort.

What is cholelithiasis?

Cholelithiasis refers to the formation of gallstones—solid deposits that develop within the gallbladder, a small organ located beneath the liver responsible for storing and concentrating bile. These stones form when there is an imbalance in the substances that make up bile, such as cholesterol, bile salts, and bilirubin, leading to crystallisation and stone formation.

Gallstones vary in size, ranging from as small as a grain of sand to as large as a golf ball. While some individuals may have a single large stone, others may develop multiple smaller ones. Many people with gallstones remain asymptomatic; however, when a stone obstructs the outflow of gallbladder or the bile duct, it can lead to significant pain and complications.

There are three primary types of gallstones:

Cholesterol stones — these are the most common type, accounting for approximately 75% of gallstones. They are primarily composed of hardened cholesterol and are typically yellow-green in color.
Pigment stones — comprising about 20–25% of gallstones, pigment stones are made up of bilirubin, a substance produced from the breakdown of red blood cells. These stones are usually dark brown or black.
Mixed stones — these contain varying proportions of cholesterol, bilirubin, and other substances. They are often found in individuals with chronic biliary infections.

In Singapore, gallstone disease is a notable health concern. Studies indicate that approximately 10–20% of adults in Singapore develop gallstones, with the risk increasing with age. Unlike Western populations where cholesterol stones predominate, research in Singapore has shown a higher proportion of pigment stones, reflecting regional dietary and genetic factors.

Symptoms

Diagnosis

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What causes cholelithiasis?

Cholelithiasis develops when substances in bile, mainly cholesterol, bilirubin, and calcium salts, crystallise and form stones within the gallbladder. Bile is normally balanced to keep these components dissolved, but several physiological and biochemical changes can disrupt this balance and trigger gallstone formation.

Excess cholesterol in bile — in many individuals, the liver produces more cholesterol than bile can dissolve. When bile becomes oversaturated, the excess cholesterol begins to crystallise. These crystals can gradually grow into stones, especially if they are not flushed out by normal gallbladder contractions. This mechanism is the leading cause of cholesterol stones, which are the most prevalent type globally.
Reduced gallbladder emptying — the gallbladder is designed to contract and release bile during digestion. When this process slows, due to fasting, low-fat diets, physical inactivity, or hormonal influences, bile can stagnate. Stagnant bile allows time for cholesterol or pigment particles to cluster and solidify into stones.
Increased bilirubin — Bilirubin is a by-product of red blood cell breakdown. When bilirubin levels are elevated, commonly due to liver disease, chronic haemolytic conditions, or biliary tract infections, it can combine with calcium to form hard, dark pigment stones. These are more often seen in individuals with chronic infections or certain blood disorders.
Excess mucin secretion — the inner lining of the gallbladder may produce high levels of mucin, a sticky glycoprotein, particularly in response to inflammation. Mucin acts as a binding surface where crystals can accumulate, further encouraging stone formation.
A multifactorial condition — in most cases, gallstones form due to a combination of these factors rather than a single cause. Metabolic conditions, genetics, diet, hormonal changes, and reduced gallbladder motility can all play a role in altering bile composition and function, setting the stage for cholelithiasis to develop.

Cholelithiasis is caused by an imbalance in bile components, such as cholesterol or bilirubin, leading to the formation of gallstones in the gallbladder.

What are the symptoms of cholelithiasis?

Many individuals with cholelithiasis remain asymptomatic, meaning the gallstones do not cause any noticeable problems. These are often referred to as “silent” gallstones and may be discovered incidentally during imaging tests for other conditions. However, when a stone obstructs the flow of bile, typically by blocking the cystic duct or common bile duct, distinct symptoms can arise.

Biliary colic — this is the most common symptom and presents as sudden, sharp pain in the upper right or central abdomen, often after eating. The pain may last from minutes to hours and can radiate to the back.
Nausea and vomiting — these frequently accompany biliary colic and are triggered by disrupted digestion and delayed gastric emptying.
Indigestion and bloating — some individuals experience a feeling of fullness, excessive burping, or general discomfort after meals, especially those high in fat.
Jaundice — yellowing of the skin and eyes may occur if a gallstone blocks the common bile duct, leading to bile buildup in the bloodstream.
Fever and chills — these suggest infection of the gallbladder or bile duct, and may indicate complications such as cholecystitis or cholangitis.
Right shoulder or back pain — in some cases, the pain from the gallbladder can radiate to the right shoulder blade or upper back due to shared nerve pathways.

Cholelithiasis can cause sudden, sharp pain in the upper abdomen, especially after eating fatty meals.

Who is at risk of cholelithiasis in Singapore?

While anyone can develop gallstones in Singapore, certain groups are more likely to be affected due to lifestyle, hormonal, genetic, or medical factors.

Older age — the risk increases significantly after the age of 40 due to changes in bile composition and gallbladder function over time.
Female sex — women are more prone to gallstones, particularly during pregnancy or when using hormonal contraceptives, due to the effect of oestrogen on cholesterol levels in bile.
Obesity and metabolic syndrome — excess body weight, insulin resistance, and high cholesterol can all contribute to bile imbalance and gallstone formation.
Rapid weight loss — losing weight quickly, especially after bariatric surgery or extreme dieting, can lead to increased cholesterol release and stone formation.
Unhealthy diet — high-fat, low-fibre eating habits common in urban settings like Singapore can increase the risk of gallstones.
Family history — having a close relative with gallstones increases the likelihood due to shared genetic and lifestyle factors.
Chronic medical conditions — people with liver disease or haemolytic disorders are at higher risk due to altered bile composition or gallbladder motility.

How can I prevent gallstones from forming?

While not all cases of gallstones can be prevented, especially when genetic or hormonal factors are involved, certain lifestyle changes can significantly lower the risk of developing them.

Maintain a healthy weight — being overweight increases the amount of cholesterol in bile, raising the risk of stone formation. Aim for gradual and sustainable weight loss if needed.
Avoid rapid dieting — losing weight too quickly can cause the liver to release more cholesterol into bile. Restrictive crash diets or post-surgical weight loss should be carefully managed.
Follow a balanced diet — include more fibre-rich foods such as fruits, vegetables, and whole grains. Limit fatty, greasy, and processed foods that can contribute to bile imbalance.
Stay physically active — regular exercise helps regulate metabolism and supports healthy gallbladder function.
Manage underlying conditions — control of diabetes, high cholesterol, or liver disease can reduce the risk of stone formation in susceptible individuals.

How is cholelithiasis diagnosed?

Diagnosis of cholelithiasis typically begins with a clinical evaluation based on symptoms and risk factors. However, confirmation requires imaging and, in some cases, blood tests to assess for complications.

Abdominal ultrasound — this is the first-line imaging test used to detect gallstones. It is non-invasive, widely available, and can accurately identify stones in the gallbladder.
CT scan — sometimes used when complications such as gallbladder inflammation or bile duct obstruction are suspected and to rule out other causes of symptoms. It is not the best imaging for gallstones.
MRI or MRCP (Magnetic Resonance Cholangiopancreatography) — a specialised MRI technique used to visualise the bile ducts in detail and identify stones lodged outside the gallbladder.
Endoscopic ultrasound (EUS) — occasionally used to detect smaller stones in the bile ducts that are not detected by standard scans.
Liver function tests — blood tests that check for elevated liver enzymes or bilirubin levels, which may indicate obstruction or inflammation of the biliary system.
Complete blood count (CBC) — may be done to assess for infection or inflammation, especially in patients presenting with fever or suspected cholecystitis.

What are the treatment options for cholelithiasis in Singapore?

Treatment is based on the presence and severity of symptoms. While silent gallstones may not need immediate action, symptomatic or complicated cases often require intervention. Dr Lee Chin Li offers an individualised approach to managing gallstone disease, combining lifestyle strategies, medical therapy, and surgery where appropriate.

Lifestyle management

Observation and monitoring — suitable for individuals with asymptomatic gallstones. The condition is monitored over time, with attention to any emerging symptoms.
Dietary adjustments — reducing intake of fatty, oily, and fried foods can ease digestion and reduce the frequency of biliary colic in mild cases.
Weight management — maintaining a healthy body weight helps reduce the risk of cholesterol stone formation. Rapid weight loss, however, should be avoided.

Medication

Oral bile acid therapy — medications such as ursodeoxycholic acid may be used to dissolve small cholesterol stones, particularly in those who are not candidates for surgery. The process is slow and recurrence is common once treatment stops.

Surgical intervention

Laparoscopic cholecystectomy — this is one of the most common treatments for symptomatic gallstones. This keyhole surgery removes the gallbladder and is associated with quicker recovery, minimal scarring, and low complication rates.
Open cholecystectomy — occasionally necessary in more complex cases, such as severe inflammation, previous upper abdominal surgery, or anatomical variations.
Endoscopic Retrograde Cholangiopancreatography (ERCP) — ERCP is used when stones have moved into the bile ducts. This non-surgical procedure allows for stone removal through an endoscope guided into the digestive tract.

Summary

Cholelithiasis, or gallstone disease, occurs when solid deposits form within the gallbladder due to imbalances in bile components such as cholesterol or bilirubin. In many cases, these stones remain silent and are discovered incidentally. However, when they obstruct the flow of bile, they can cause a range of symptoms including sharp abdominal pain, nausea, jaundice, or digestive discomfort. The condition is particularly common in Singapore, with risk increasing in individuals over 40, women—especially during pregnancy or while using hormonal therapies—those with obesity, rapid weight loss, or underlying health conditions such as diabetes. Diagnosis typically involves ultrasound imaging, supported by blood tests where needed. Management depends on the severity of symptoms and may include lifestyle modification, oral medication for selected cases, or gallbladder removal through keyhole surgery.

If you are experiencing symptoms or have concerns about gallstones, schedule a consultation with us for a detailed diagnosis and personalised treatment plan.

Frequently Asked Questions (FAQs)

Why are women more prone to gallstones?

Women have a higher risk due to elevated oestrogen levels, especially during pregnancy or when using hormonal contraceptives, which can increase cholesterol in bile and slow gallbladder emptying.

Can gallstones affect pregnancy?

Yes, hormonal changes during pregnancy can increase the risk of gallstone formation. If symptomatic, management may include dietary adjustments or, in severe cases, surgical intervention during the second trimester.

Are gallstone symptoms different in women?

While symptoms are generally similar, women may experience referred pain more frequently, such as discomfort in the shoulder or back.

Can hormonal contraceptives increase gallstone risk?

Yes, oestrogen in contraceptives can raise cholesterol levels in bile, potentially leading to gallstone formation.

Is gallbladder removal safe during pregnancy?

Laparoscopic cholecystectomy is considered safe during the second trimester if necessary, but elective surgeries are often postponed until after delivery when possible.

Can diet prevent gallstones?

A balanced diet rich in fibre and healthy fats, combined with regular meals and gradual weight loss if needed, may reduce the risk of gallstones.

Do gallstones recur after treatment?

If the gallbladder is removed, gallstones typically do not recur. However, if only the stones are removed or dissolved, there is a possibility of recurrence.

What are the signs I should see a doctor?

Seek medical attention if you experience severe abdominal pain, especially in the upper right quadrant, nausea, vomiting, fever, or jaundice.

Are there non-surgical treatments for gallstones?

Medications can dissolve certain types of gallstones, but they are less effective and slower than surgical options. Surgery is often recommended for symptomatic cases.

Can I live normally without a gallbladder?

Yes, most people lead normal lives post-cholecystectomy, though some may need to adjust their diet to manage digestive changes.

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for Personalised Gallstone Treatment

Every patient’s condition is unique. Book a consultation with Dr Lee to discuss your symptoms, get a thorough diagnosis, and explore the most suitable treatment options—including whether surgery is right for you.