Gallstones in Nepal: Symptoms, Causes and When Surgery is Needed

Gallstone disease is one of the most common surgical conditions in Nepal. Ultrasound studies consistently reveal a prevalence of 10–25% in adult populations, with significantly higher rates in women. Many people carry gallstones for years without knowing it. The challenge is understanding when to treat stones that have become symptomatic and when complications demand urgent surgical intervention.

What Are Gallstones and Why Does Nepal Have High Prevalence?

Gallstones are solid deposits that form in the gallbladder when the bile it stores becomes oversaturated with cholesterol, bilirubin, or calcium salts. Stones range in size from sand-grain particles to golf-ball-sized masses and may number from one to hundreds.

Nepal’s high gallstone prevalence is driven by several intersecting factors:

Dietary pattern: Traditional Nepali diets — high in refined carbohydrates (white rice, maida), moderate in fat, and relatively low in fiber — promote bile cholesterol supersaturation. Rapid dietary transition in urban areas toward processed and high-fat foods compounds this.

Ethnicity: South Asian populations, including Nepali ethnic groups, have an intrinsically higher cholesterol lithogenicity (tendency to form cholesterol crystals in bile) than European populations.

Female gender: Estrogen increases cholesterol secretion into bile. Women have 2–3 times higher gallstone prevalence than men. Oral contraceptive use and multiple pregnancies further increase risk.

Obesity: Obesity is an independent risk factor for cholesterol gallstones. Nepal’s urbanizing population is experiencing rising BMI rates.

Rapid weight loss: Crash dieting and bariatric surgery accelerate gallstone formation by concentrating bile during periods of fat mobilization.

Hemolytic conditions: Sickle cell disease, hereditary spherocytosis, and malaria-related chronic hemolysis lead to pigment stone formation from excess bilirubin in bile.

What Are the Types of Gallstones?

Cholesterol gallstones account for approximately 80% of stones in Western and South Asian populations. Yellow-green, often solitary or few in number. Form when bile is supersaturated with cholesterol.

Pigment gallstones are brown or black, formed from calcium bilirubinate. Brown pigment stones are associated with biliary infection. Black pigment stones are associated with chronic hemolytic conditions and cirrhosis. More common in East Asian populations but seen in Nepal with hemolytic disease backgrounds.

Mixed stones contain cholesterol, calcium salts, and pigment in varying proportions. Most clinically encountered gallstones are mixed.

What Are the Symptoms of Gallstones?

Silent gallstones (asymptomatic): Approximately 70–80% of people with gallstones are asymptomatic. Stones are discovered incidentally on ultrasound performed for other reasons.

Biliary colic: The characteristic symptom of symptomatic gallstones. A gallstone temporarily obstructs the cystic duct, causing the gallbladder to contract against the obstruction. Presents as:

• Severe, cramping or constant pain in the right upper abdomen or epigastrium (upper central abdomen)
• Radiation to the right shoulder tip or between the shoulder blades
• Typically begins 30–60 minutes after a fatty meal
• Duration: 30 minutes to 6 hours, then resolves spontaneously
• Associated nausea and vomiting
• No fever in simple biliary colic

Fatty food intolerance: Bloating, right upper abdominal discomfort, nausea, or belching after fatty meals. Less specific than biliary colic but common in gallstone disease.

Should Silent Gallstones Be Treated?

The management of asymptomatic (silent) gallstones is an important and sometimes misunderstood question. The evidence supports watchful waiting for most asymptomatic gallstones.

Reasons to treat silent stones (surgery recommended):

• Large stones (above 3 cm) — higher lifetime risk of gallbladder cancer
• Porcelain gallbladder (calcified gallbladder wall)
• Gallbladder polyp with gallstones — increased malignancy risk
• Patient undergoing gastric bypass surgery (biliopancreatic diversion changes bile composition, dramatically increasing post-surgery stone complications)
• Symptomatic gallstones in pregnancy — surgery is deferred to second trimester if possible, but symptomatic stones cannot be safely ignored

Watchful waiting is appropriate for:

• Asymptomatic stones without the above risk factors
• Small stones in elderly patients with significant co-morbidity

The annual risk of a silent stone becoming symptomatic is approximately 1–2%. The risk of serious complication (pancreatitis, cholangitis) without preceding symptoms is very low.

When Do Gallstones Become Dangerous?

Gallstones cause dangerous complications when they migrate from the gallbladder into the bile ducts or when the gallbladder becomes severely inflamed.

Acute cholecystitis: Gallstone impacted in the cystic duct causes gallbladder wall inflammation. Right upper quadrant pain that persists beyond 6 hours, fever, and right subcostal tenderness distinguish acute cholecystitis from simple biliary colic. Requires hospital admission.

Choledocholithiasis (common bile duct stones): A stone migrates from the gallbladder into the common bile duct. Causes biliary obstruction. Presentation: jaundice (yellow skin and eyes), dark urine, pale stools, right upper abdominal pain. Stones are cleared by ERCP (endoscopic retrograde cholangiopancreatography) before or after cholecystectomy.

Acute cholangitis: Bacterial infection of an obstructed bile duct. Presents as Charcot’s triad: right upper abdominal pain, fever with rigors, and jaundice. Can progress to septic shock (Reynold’s pentad adds hypotension and confusion). A life-threatening emergency requiring urgent biliary drainage, IV antibiotics, and fluid resuscitation.

Gallstone pancreatitis: A small stone migrates through the common bile duct and blocks the pancreatic duct at the ampulla of Vater. Causes acute pancreatitis — severe epigastric pain radiating to the back, elevated serum amylase and lipase, vomiting. Can be mild and self-limiting or severe with pancreatic necrosis.

These complications require immediate hospital care.

How Are Gallstones Diagnosed?

Ultrasound abdomen: The primary investigation for gallstones. Highly accurate (sensitivity >95%) for stones within the gallbladder. Hyperechoic foci with posterior acoustic shadowing — the classic ultrasound appearance. Also assesses gallbladder wall thickness, pericholecystic fluid (cholecystitis), and common bile duct diameter.

Liver function tests (LFTs): Bilirubin, ALP, and GGT are elevated with bile duct obstruction. ALT and AST elevation suggests hepatocyte involvement.

Serum amylase and lipase: Elevated in gallstone pancreatitis.

CT scan: Used when ultrasound is inconclusive, when complications (perforation, abscess) are suspected, or when surgical planning for complex cases is required.

MRCP (Magnetic Resonance Cholangiopancreatography): Non-invasive imaging of the bile ducts. Detects common bile duct stones with high accuracy without the procedural risk of ERCP.

Does Dissolution Therapy Work for Gallstones?

Oral ursodeoxycholic acid (UDCA) can dissolve small (less than 5 mm), purely cholesterol, floating gallstones in a functioning gallbladder. The limitations make this approach rarely used:

• Effectiveness limited to small, pure cholesterol stones (minority of stones)
• Requires 6–24 months of treatment
• Recurrence rate of 50% within 5 years of stopping treatment
• Symptoms may persist during treatment

Dissolution therapy is occasionally used in patients unfit for surgery who have uncomplicated, small cholesterol stones. It is not a substitute for surgery in patients with symptomatic stones who are fit for cholecystectomy.

Gallstone Diagnosis and Treatment at A&B International Hospital, Pokhara

A&B International Hospital

Pokhara-02, Bindhyaabasini Way to Sarangkot

Phone: +977 061-412512

Website: abinthospital.com

Ultrasound diagnosis, specialist surgical consultation, and laparoscopic cholecystectomy. ECHS empanelled. If you have been told you have gallstones — do not wait for a complication. Call us to understand your options.