Can you still get gallstones without a gallbladder?

Gallstones After Cholecystectomy: Occurrence and Management

Yes, you can still develop gallstones even without a gallbladder, specifically in the bile ducts. While cholecystectomy removes the primary site of gallstone formation, stones can still form in the bile ducts (common bile duct stones or choledocholithiasis).

Types of Gallstones After Cholecystectomy

• Primary bile duct stones can form in the absence of a gallbladder, particularly in the common bile duct or intrahepatic ducts 1
• These stones are typically brown-pigment stones (calcium bilirubin stones), differing from the cholesterol or black-pigment stones commonly found in the gallbladder 1
• Primary bile duct stones are more common in East Asian countries than in Western populations 1
• In some cases, cholesterol stones can form directly in the common bile duct even without gallbladder stones 2

Risk Factors for Post-Cholecystectomy Gallstones

• Recurrent common bile duct stones occur in approximately 5.9-11.3% of patients with an empty gallbladder in situ (following duct clearance) 3
• This rate is significantly lower than the 15-23.7% recurrence rate observed in patients who still have their gallbladder with residual gallbladder stones 3
• Dietary factors that may increase risk include:
  • High cholesterol intake
  • Saturated fat consumption
  • Trans fatty acids
  • Refined sugar 4

Clinical Presentation

• Post-cholecystectomy bile duct stones may present with:
  • Episodic upper abdominal pain (severe, located in epigastrium and/or right upper quadrant)
  • Obstructive jaundice
  • Cholangitis 2, 5
• Some patients may have presentations that mimic malignant lesions, making diagnosis challenging 2
• The pain is typically steady in intensity, may radiate to the upper back, be associated with nausea, and lasts for hours up to a day 5

Diagnosis

• Endoscopic retrograde cholangiopancreatography (ERCP) is effective for diagnosing the presence of common bile duct stones 2
• Other diagnostic modalities include:
  • Ultrasonography
  • Magnetic resonance cholangiopancreatography (MRCP)
  • Endoscopic ultrasound 3

Management Options

• Endoscopic intervention is the primary treatment for symptomatic bile duct stones 6
• Therapeutic sphincterotomy can lead to subsidence of cholangitis and retrieval of stones 2
• In some cases, nasobiliary decompression may be required if stones cannot be retrieved endoscopically 2
• For patients with acute cholangitis, immediate anti-infective therapy is mandatory 6
• In rare cases, surgical intervention may be necessary for patients with severe cholangitis or when endoscopic approaches fail 2

Prevention Strategies

• Dietary modifications that may help prevent gallstone formation:
  • Increased consumption of polyunsaturated fat
  • Monounsaturated fat
  • Fiber
  • Caffeine
  • Vegetarian diet 4
• Nutritional supplements that might help prevent gallstones include:
  • Vitamin C
  • Soy lecithin
  • Iron 4
• Ursodeoxycholic acid can reduce the risk of gallstone formation in specific situations such as significant weight reduction 6

Key Considerations

• While cholecystectomy eliminates the primary site of gallstone formation, it does not completely eliminate the risk of developing stones in the bile ducts 1
• The pathogenesis of primary bile duct stones differs from that of gallbladder stones, which explains why they can still form after cholecystectomy 1
• Patients who have undergone cholecystectomy should be aware of symptoms that might indicate bile duct stones and seek medical attention if they experience severe upper abdominal pain, jaundice, or signs of infection 5