Gallbladder and Biliary Disease: Understanding Stones, Cholangitis, and ERCP

When your gallbladder stops working right, the pain doesn’t just come and go-it hits like a wave you can’t swim through. Imagine a sudden, sharp grip under your right ribs that lasts for hours, maybe with fever, yellowing skin, or nausea that won’t quit. This isn’t just indigestion. It’s your bile system screaming for help. Gallbladder and biliary diseases affect 10-15% of adults in developed countries, and for many, it starts with stones.

What Are Gallstones, Really?

Gallstones aren’t just lumps of junk. They’re crystals formed inside your gallbladder when bile gets out of balance. About 80% are made of cholesterol, the same kind found in your blood. The other 20% are pigment stones, mostly bilirubin, a breakdown product of red blood cells. Mixed stones fall in between. These stones can be as small as grains of salt or as big as golf balls.

Most people with gallstones never know they have them. In fact, the American College of Gastroenterology says asymptomatic stones don’t need treatment. The risk of complications from surgery is higher than the chance those stones will cause trouble-only about 1-2% of people with silent stones develop symptoms each year. But when they do, it’s serious. Blockage of the cystic duct leads to acute cholecystitis-inflammation of the gallbladder. Blockage in the common bile duct? That’s when things get dangerous.

Cholangitis: When Infection Hits the Bile Duct

Cholangitis is a bacterial infection of the bile ducts. It’s not common, but it’s life-threatening. The classic signs? Charcot’s triad: severe pain in the upper right abdomen, fever, and jaundice (yellow skin or eyes). If you add confusion or low blood pressure, you’re looking at Reynolds’ pentad-a sign of septic shock.

Most cases happen because a gallstone gets stuck in the common bile duct, trapping bacteria that normally live in the gut. These bugs multiply fast in the blocked, stagnant bile. Without treatment, mortality can hit 10-20%. That’s why doctors don’t wait. If you have these symptoms, you need urgent care.

It’s also why ERCP isn’t just a test-it’s often an emergency procedure. In the U.S., over 500,000 hospital admissions each year are tied to complications from gallstones, including cholangitis and pancreatitis. And women are affected more than men-2.1 times more often. Why? Hormones. Estrogen increases cholesterol in bile, and pregnancy, birth control, and hormone therapy all raise the risk.

ERCP: The Procedure That Fixes Blocked Ducts

Endoscopic Retrograde Cholangiopancreatography, or ERCP, is a hybrid procedure-part endoscopy, part X-ray, part surgery. A thin, flexible tube with a camera is passed through your mouth, down your throat, into your stomach, and into the first part of your small intestine. There, the doctor finds the opening where the bile duct empties-the ampulla of Vater.

They inject dye, take X-rays, and look for stones or narrowing. If they find a stone blocking the duct, they use tiny tools to cut the muscle around the opening (sphincterotomy), grab the stone with a basket, or break it up. Success rates? 85-95% in experienced hands. It’s the gold standard for removing bile duct stones.

But it’s not risk-free. About 3-10% of patients develop post-ERCP pancreatitis-the most common complication. It happens when the procedure irritates the pancreas. Some patients need to stay in the hospital for days. That’s why experts now recommend using MRCP (magnetic resonance cholangiopancreatography) first. MRCP is non-invasive, has 95% sensitivity, and doesn’t carry the same risks. Only if MRCP shows stones should you go ahead with ERCP.

And here’s a critical gap: only 30-40% of patients with bile duct stones get ERCP done at the same time as their gallbladder removal. That means many people go through two surgeries, two recoveries, and two sets of risks. Better coordination between surgeons and gastroenterologists could cut that number in half.

What About Other Treatments?

You might hear about pills to dissolve stones. Ursodeoxycholic acid (UDCA) can work-but only for small cholesterol stones under 15mm. Even then, it takes 6-12 months and only works in 30-40% of cases. And it does nothing for pigment stones. Plus, stones come back in 50% of people within five years if the gallbladder stays in place.

Shock wave therapy? Used to be popular. Now it’s rarely used. It breaks stones into pieces, but those pieces often get stuck and cause more blockages. Recurrence rates are too high.

Laparoscopic cholecystectomy-removing the gallbladder through small cuts-is the go-to for symptomatic gallstones. It’s done in 90% of cases. Recovery? Most people go home in 1-2 days and back to work in 7-10 days. Compare that to open surgery: 4-6 weeks off work, a long scar, and more pain.

After gallbladder removal, some people get diarrhea. Not everyone. About 10-15% report ongoing loose stools, especially after fatty meals. That’s because bile flows continuously into the intestine instead of being stored. Most adjust within weeks. Some need loperamide or a low-fat diet for months. It’s not dangerous, but it’s inconvenient.

Who’s at Risk?

Gallstones aren’t random. Certain groups are far more likely to get them:

• Women: Especially after pregnancy, on birth control, or hormone therapy.
• Over 60: Risk jumps to 25% in older adults.
• Obese: BMI over 30 doubles or triples your risk.
• Rapid weight losers: Losing more than 1.5kg per week ups your chance.
• Diabetics: Two to three times more likely to develop stones.
• Native Americans: Up to 64% of Pima Indians have gallstones-the highest rate in the world.
• Asian populations: Higher rates of pigment stones due to diet and genetics.

Even cirrhosis increases your risk by 4-6 times. That’s because liver damage changes how bile is made and processed.

What Happens After ERCP or Surgery?

Recovery isn’t just about healing-it’s about adjusting. After ERCP, you’ll have a sore throat from the scope. That lasts a few days. You’ll be monitored for pancreatitis signs: abdominal pain, nausea, fever. Most people go home the same day if all’s well.

After gallbladder removal, you’ll be told to eat low-fat for 2-4 weeks. Then, slowly reintroduce fats. Most people resume normal eating by 6 weeks. But here’s the truth: you don’t need to avoid fat forever. Your liver still makes bile. It just doesn’t store it. So you might need to eat smaller meals and avoid large amounts of fried food.

Some patients develop post-cholecystectomy syndrome-persistent pain or bloating after surgery. That happens in about 12% of cases. It could be from leftover stones, bile duct injury, or even functional gut issues. If it lasts, you need more tests.

What’s New in 2026?

Technology keeps improving. In 2023, the FDA approved a new duodenoscope with a fully disposable elevator. That’s huge. Between 2013 and 2018, faulty scopes caused 112 outbreaks of drug-resistant infections. Now, the part that bends and moves is single-use-no more cleaning nightmares.

Intraductal ultrasound (IDUS) is also gaining ground. It uses a tiny ultrasound probe inside the bile duct during ERCP. It spots stones under 5mm that standard imaging misses. Sensitivity jumps to 92% from 75%.

Researchers are now working on drugs to dissolve pigment stones-something that doesn’t exist yet. Right now, if you have pigment stones, surgery or ERCP is your only option.

Telehealth follow-ups after ERCP are cutting readmissions by 18% in pilot programs. Patients get a video check-in on day 2 or 3. If they have pain or fever, they’re seen right away. No waiting until it’s bad.

What Should You Do If You Suspect a Problem?

If you have sudden, severe pain under your right ribs, especially with fever or yellow skin:

1. Go to the ER. Don’t wait.
2. Ask for an ultrasound first. It’s quick, safe, and finds gallstones in 84% of cases.
3. If the bile duct is suspected, ask about MRCP-not ERCP yet.
4. If stones are found in the duct, make sure your surgeon and endoscopist coordinate. Same-day ERCP during cholecystectomy saves you from a second procedure.
5. Don’t push for surgery if you have no symptoms. Watchful waiting is safer.

And if you’ve had your gallbladder out and still have issues? Don’t assume it’s normal. Talk to your doctor. There are answers.

It’s not just about removing a stone or a gallbladder. It’s about understanding how your body moves bile, why it gets blocked, and how to prevent complications before they become emergencies. Knowledge is the best tool you have.