Gallstone attack: symptoms, help, and treatment

Important: Severe or unusual abdominal pain, especially accompanied by fever, jaundice, chills, repeated vomiting, weakness, confusion, or a drop in blood pressure, requires urgent medical evaluation. It is impossible to reliably distinguish simple biliary colic from the onset of a complication based on external sensations.

What happens during a gallstone attack?

Gallstone disease refers to the formation of stones in the gallbladder or bile ducts. Most stones cause no symptoms for a long time. An attack occurs not simply because a stone is present in the gallbladder, but mainly when it migrates to the area where bile flows out through the cystic duct, temporarily blocking the flow of bile. This condition is commonly referred to as biliary colic, or a gallbladder attack. [1]

After eating, the gallbladder contracts and pushes bile into the intestines. If a stone blocks the cystic duct, bile cannot exit normally. Pressure inside the gallbladder increases, its wall stretches, smooth muscle contractions intensify, and pain-stimulating nerve endings are activated. This is why an attack sometimes begins some time after eating, although there may not be a clear connection to a specific food. [2]

The word "colic" can be misleading. With intestinal or renal colic, the pain often comes in distinct waves, whereas classic biliary pain, after increasing, usually becomes quite constant. It can be very intense, persisting for tens of minutes or several hours, after which it gradually subsides as the stone dislodges and bile flow is restored. [3]

If the stone remains in the cystic duct and the obstruction persists, the mechanical attack can progress to acute calculous cholecystitis. In this case, inflammation of the gallbladder wall occurs in addition to the distension of the gallbladder. The pain becomes more persistent, localized tenderness develops, and some patients experience fever and changes in blood counts. [4]

A stone can also move in the opposite direction, exiting the gallbladder into the common bile duct. This can lead to obstruction of bile flow, mechanical jaundice, acute cholangitis, or acute pancreatitis. This is why the same initial symptom—severe upper abdominal pain—can indicate both relatively uncomplicated biliary colic and a potentially dangerous condition. [5]

Table 1. What can happen during a "gall attack"

Situation	What happens to the stone?	The main consequence
Asymptomatic stone	Freely located in the gallbladder	There are no symptoms
Biliary colic	Temporarily occludes the cystic duct	Severe pain without significant inflammation
Acute calculous cholecystitis	The cystic duct obstruction persists	Inflammation of the gallbladder
Choledocholithiasis	The stone enters the common bile duct	Bile outflow obstruction
Acute cholangitis	Obstruction is associated with bile duct infection.	Fever, jaundice, risk of sepsis
Acute biliary pancreatitis	The stone interferes with the outflow of pancreatic secretions.	Inflammation of the pancreas

Table source: National Institute of Diabetes and Digestive and Kidney Diseases, USA. [6]

How a typical attack begins and feels

Classic biliary pain most often occurs in the right hypochondrium or in the upper central abdomen—the epigastric region. Therefore, the patient does not always directly indicate the location of the gallbladder. Sometimes the sensation is perceived as "stomach pain," pressure under the sternum, or a deep ache under the right costal arch. [7]

Pain can radiate to the back, under the right shoulder blade, or into the right shoulder. This type of pain is called referred pain and is associated with the peculiarities of nerve transmission from the gallbladder. Radiation helps the physician suspect a biliary origin of the symptoms, but is not a mandatory sign and does not in itself confirm the diagnosis. [8]

The intensity can be very high. Patients describe the attack as a deep, pressing, bursting, burning, or squeezing pain. It usually increases over a short period of time, reaches a stable level, and then persists. Second-long tingling sensations or short attacks lasting one to two minutes are significantly less typical of gallstones. [9]

Duration is of great diagnostic importance. An uncomplicated attack typically lasts from several dozen minutes to several hours and ends when the obstruction disappears. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) specifically warns that pain persisting for several hours requires medical evaluation, as prolonged obstruction increases the likelihood of complications. [10]

Nausea during an attack is common, and vomiting may occur occasionally or repeatedly. With simple biliary colic, high fever, severe chills, or persistent jaundice are not expected. The appearance of these symptoms should lead one to suspect not just a "severe attack," but a complication of gallstone disease. [11]

Table 2. Typical picture of biliary colic

Sign	What is typical
Localization	Right hypochondrium or epigastrium
Start	Relatively fast
Character	Severe persistent pain after the initial build-up
Irradiation	Back, right shoulder blade, right shoulder
Duration	Usually tens of minutes - several hours
Nausea	Often
Vomit	Possible
High temperature	It is not typical for simple colic
Jaundice	It is not typical for simple colic
Between attacks	Possible complete absence of symptoms

Table source: National Institute of Diabetes and Digestive and Kidney Diseases, USA. [12]

Why does an attack often occur after eating and can start at night?

The entry of food into the duodenum triggers a physiological mechanism of gallbladder contraction. This response may be particularly pronounced after eating foods containing significant amounts of fat. If a mobile stone is located in the cystic duct, gallbladder contraction can lead to its impaction and pain. [13]

However, the rule that "an attack only occurs after fatty foods" is incorrect. The gallbladder also functions after a normal meal, so biliary colic can occur after a relatively light meal or even without any obvious dietary trigger. A lack of reaction to fried or fatty foods does not rule out gallstones. [14]

Attacks typically occur in the evening and at night. The National Institute of Diabetes and Digestive and Kidney Diseases notes that episodes often develop after a large meal and often occur in the evening or nighttime. This is one reason why patients with previously asymptomatic stones first present to the emergency department at night. [15]

After the attack ends, a feeling of almost complete well-being may set in. A person wakes up pain-free in the morning and assumes the illness has passed. In reality, the cessation of colic usually only means that the stone has shifted and is no longer blocking the duct; the stones themselves remain. [16]

After the first true attack, the likelihood of recurrent episodes increases. A modern meta-analysis of randomized trials from 2025 showed that biliary complications and recurrent colic were more common with conservative management of symptomatic gallstone disease than after early gallbladder removal. An updated meta-analysis from 2026 also confirmed the benefit of cholecystectomy in reducing recurrent biliary pain, although conservative observation remains an option for selected patients. [17] [18]

Table 3. What can provoke or accompany an attack

Factor	Possible role
A large meal	Enhances gallbladder contraction
Fatty foods	May more actively stimulate bladder emptying
Night period	Attacks often occur in the evening or at night
Long-term absence of symptoms	Does not exclude a sudden new attack
The presence of small mobile stones	May promote migration into ducts
Previous biliary colic	Increases the likelihood of new episodes

Table source: National Institute of Diabetes and Digestive and Kidney Diseases. [19]

How to distinguish between common biliary colic and acute cholecystitis

The most important task during an attack is not simply to confirm the presence of stones, but to determine whether the situation remains uncomplicated. In simple biliary colic, a stone temporarily obstructs the cystic duct but then moves. In acute calculous cholecystitis, the obstruction persists and an inflammatory process in the gallbladder wall begins. [20]

With cholecystitis, pain typically becomes prolonged and more localized in the right hypochondrium. The abdomen is tender to pressure, and taking a deep breath during palpation of the gallbladder area can sharply intensify the pain. This clinical phenomenon is known as Murphy's sign, but its absence does not rule out inflammation. [21]

An additional signal is an increase in body temperature. In uncomplicated colic, fever is usually absent, whereas in cholecystitis, the inflammatory reaction may be accompanied by fever, an increased white blood cell count, and increased concentrations of laboratory markers of inflammation. [22]

The Tokyo International Guidelines recommend basing the diagnosis not on a single symptom, but on a combination of local inflammatory symptoms, a systemic inflammatory response, and characteristic imaging findings. This is important because neither pain intensity, nor temperature, nor any single laboratory test are sufficiently accurate. [23]

In confirmed acute calculous cholecystitis, the current strategy is primarily focused on early laparoscopic gallbladder removal. The World Society for Emergency Surgery considers early surgery as the standard for most patients if surgical intervention is feasible, and British guidelines recommend early laparoscopic cholecystectomy within one week of diagnosis. [24] [25]

Table 4. Biliary colic and acute cholecystitis

Sign	Biliary colic	Acute calculous cholecystitis
Obstruction	Temporary	More durable
Pain	Usually stops	It continues
Temperature	Usually normal	Often elevated
Chills	Atypical	Possible
Local pain	It can be moderate	Usually expressed
Murphy's sign	May be absent	Often present
Inflammatory blood markers	Usually without significant changes	Often elevated
Gallbladder wall	No inflammatory changes	Thickening and swelling may occur.
Tactics	Pain management and routine evaluation	Urgent medical care

Source of table: Tokyo International Guidelines. [26]

When the attack is associated with a common bile duct stone, cholangitis or pancreatitis

A stone can pass from the gallbladder and enter the common bile duct. This condition is called choledocholithiasis. The clinical presentation varies: some stones are discovered incidentally, others cause biliary pain, and persistent obstruction can lead to jaundice, dark urine, and light-colored stool. [27]

If a bacterial infection develops against the background of bile duct obstruction, acute cholangitis occurs. Classically, it is described as a combination of pain in the right upper quadrant, fever, and jaundice. However, the Tokyo Guidelines emphasize that the absence of a complete classical picture does not rule out the disease: the diagnosis is assessed based on signs of inflammation, cholestasis, and visual evidence of obstruction. [28]

Cholangitis is a potentially dangerous condition, as bile duct infection can quickly develop into a systemic infection with organ dysfunction. In moderate to severe cases, early or urgent endoscopic restoration of bile flow may be required in addition to antimicrobial therapy and intensive monitoring. [29]

Another risk associated with a small migrating stone is acute pancreatitis. The stone can temporarily block the outlet of the common bile duct and pancreatic duct, impairing the flow of pancreatic secretions. This condition is characterized by severe, prolonged pain in the upper central abdomen, often radiating to the back, along with severe nausea and vomiting. [30]

The American College of Gastroenterology, in its 2024 guidelines, recommends performing ultrasound in acute pancreatitis to search for a biliary cause. In mild biliary pancreatitis, gallbladder removal is preferred before hospital discharge, whereas in cases of concurrent cholangitis, early endoscopic restoration of bile flow is indicated. [31]

Table 5. How do complications of an attack differ?

State	Pain	Temperature	Jaundice	Characteristic additional signs
Biliary colic	Strong, but stops	Usually no	No	Nausea
Acute cholecystitis	Continuous on the right	Often	Usually no	Severe pain
Choledocholithiasis	It may be paroxysmal.	Not necessarily	Possible	Dark urine, light stool
Acute cholangitis	Severe pain may occur	Often	Often	Chills, risk of systemic infection
Gallbladder pancreatitis	Severe constant pain	Possible	Possible	Radiation to the back, severe vomiting

Table source: American College of Gastroenterology.[32]

What to do during an attack at home

If a person has been previously examined, the diagnosis of gallstone disease is confirmed, and a short, habitual attack without alarming symptoms occurs, the first step is to stop eating heavy foods and monitor the progress of the condition. The UK's National Institute for Health and Care Excellence recommends avoiding foods and drinks that individually trigger biliary symptoms until definitive treatment is established. [33]

Painkillers are used to reduce pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) have been the most thoroughly studied. A Cochrane systematic review found that they are significantly more effective than placebo in reducing pain in biliary colic. Compared to antispasmodic drugs, evidence also emerged in favor of more effective pain relief, although the quality of some studies is limited. [34]

However, there is no universal "best medicine for an attack." Nonsteroidal anti-inflammatory drugs may be contraindicated in cases of gastrointestinal bleeding, peptic ulcer disease, severe renal impairment, certain cardiovascular diseases, allergies, and certain drug combinations. Therefore, it is helpful for patients with established gallstones to discuss a personalized pain management plan with their physician in advance. [35]

Antispasmodics can be used for symptomatic treatment, but they do not eliminate the stone or guarantee relief of obstruction. In one randomized trial, diclofenac provided more rapid and significant relief of biliary pain than hyoscine butylbromide. These results do not imply that a specific drug should be prescribed to every patient, but they demonstrate the limitations of the "biliary colic = antispasmodic is enough" concept. [36]

The main mistake in home treatment is to continue to suppress pain for many hours, ignoring changes in symptoms. The disappearance of pain after medication does not prove that the obstruction has been resolved. If pain persists or returns, or if fever, jaundice, repeated vomiting, chills, or significant deterioration in health occur, a medical evaluation is required. [37]

Table 6. What should and should not be done during an attack

Action	Modern approach
Stop eating heavy foods during severe pain	Reasonable
Use a pain reliever approved by your doctor in advance	Reasonable
Monitor the duration of pain	Necessarily
Measure temperature	Healthy
Pay attention to the color of your skin, urine and stool	Healthy
Start antibiotics on your own	You shouldn't
Relying solely on antispasmodics for pain that lasts for hours	You shouldn't
Trying to "expel the stone" with choleretic agents	Not a standard of care
Endure pain with fever or jaundice at home	Dangerous
Postpone treatment if the condition worsens	Dangerous

Table source: National Institute of Diabetes and Digestive and Kidney Diseases, USA. [38]

When to seek urgent medical attention

The duration of pain is one of the most important indicators. The National Institute of Diabetes and Digestive and Kidney Diseases recommends seeking immediate medical attention if pain persists for more than a few hours. This is because prolonged obstruction increases the risk of cholecystitis, choledocholithiasis, and pancreatitis. [39]

Fever or chills accompanied by pain are worrisome signs. They may indicate gallbladder inflammation or a bile duct infection. Severe chills combined with jaundice and pain are especially dangerous, as this combination requires ruling out acute cholangitis. [40]

Yellowing of the whites of the eyes or skin, darkening of the urine, and noticeably lighter stool are signs of bile obstruction. A common bile duct stone may move periodically, so the intensity of pain does not necessarily reflect the degree of obstruction. Even if the pain subsides, recurrence of jaundice requires investigation. [41]

Severe, persistent epigastric pain radiating to the back and repeated vomiting requires the exclusion of acute pancreatitis. Severe pancreatitis can cause a systemic inflammatory response, affecting the lungs, kidneys, and cardiovascular system, so severe, prolonged pain should not be treated solely at home. [42]

Confusion, severe weakness, fainting, a drop in blood pressure, rapid breathing, or a significant deterioration in general condition are signs of possible organ dysfunction or systemic infection. These symptoms require immediate medical attention, regardless of how well a person knows about their stones. [43]

Table 7. Red flags during an attack

Symptom	Possible cause	Necessary action
The pain lasts for several hours	Cholecystitis or persistent obstruction	Urgent assessment
Temperature	Inflammation or infection	Urgent assessment
Chills	Possible cholangitis	Urgent Care
Jaundice	Common bile duct stone	Urgent examination
Dark urine	Bile outflow obstruction	Urgent examination
Light-colored stool	Severe cholestasis	Urgent examination
Repeated vomiting	Pancreatitis or other complication	Urgent assessment
The pain radiates to the back and does not go away.	Possible pancreatitis	Urgent examination
Confusion	Severe infection is possible	Emergency assistance
Drop in blood pressure	Organ dysfunction is possible	Emergency assistance

Source of table: Tokyo International Guidelines for Acute Cholangitis. [44]

How is a seizure diagnosed in a hospital?

Diagnosis begins with a detailed description of the symptoms. The doctor determines the exact location and duration of the pain, its relationship to diet, whether it radiates to the back or shoulder, and whether there is fever, jaundice, chills, vomiting, or previous similar episodes. This is necessary because pain in the right hypochondrium can be associated not only with the gallbladder, but also with the liver, pancreas, stomach, duodenum, lungs, and musculoskeletal disorders. [45]

Ultrasound is the primary initial imaging modality for suspected biliary pathology. It can detect gallstones, assess gallbladder size and wall structure, the presence of fluid around the gallbladder, and bile duct dilation. The American College of Radiology considers ultrasound a key initial imaging modality for suspected gallbladder disease. [46]

Blood tests are also performed. The UK's National Institute for Health and Care Excellence recommends liver function tests and an ultrasound scan if gallstones are suspected. In acute cases, a complete blood count, inflammatory markers, and, if pancreatitis is suspected, lipase levels are also assessed. [47]

If ultrasound does not detect a common bile duct stone, but the duct is dilated or liver function tests are abnormal, the next step may be magnetic resonance imaging of the bile and pancreatic ducts. If uncertainty persists, endoscopic ultrasound is considered. [48]

Computed tomography (CT) is not a mandatory initial investigation for every attack and may miss some gallstones. However, it is particularly useful when the clinical presentation is atypical, complications need to be assessed, or other abdominal diseases need to be ruled out. The American College of Radiology recommends choosing further imaging based on the results of the initial ultrasound examination and the clinical probability of disease. [49]

Table 8. Examination during an attack

Study	What helps to determine
Ultrasound examination	Gallstones and gallbladder condition
Complete blood count	Possible inflammatory reaction
Bilirubin	Bile outflow obstruction
Liver enzymes	Possible obstruction of the biliary tree
Lipase	Acute pancreatitis
Magnetic resonance imaging of the bile ducts	Common bile duct stones
Endoscopic ultrasound examination	Very small stones and unclear cases
Computed tomography	Complications and alternative causes of pain
Hepatobiliary scintigraphy	Possible cystic duct obstruction with unclear diagnosis

Table source: American College of Radiology.[50]

How is an attack treated and what happens after it ends?

In uncomplicated biliary colic, the primary goal is effective pain relief and the prevention of complications. Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most studied agents. A Cochrane analysis of randomized trials confirmed their effectiveness against pain compared with placebo, although the reliability of data on complication prevention is significantly lower. [51]

If acute cholecystitis is diagnosed, treatment is no longer limited to pain relief. The severity of the inflammation, the need for antimicrobial therapy, and the possibility of early surgical intervention are assessed. The World Society for Emergency Surgery considers early laparoscopic cholecystectomy preferable for most surgically fit patients. [52]

If a common bile duct stone is present, the underlying obstruction must be addressed. The UK's National Institute for Health and Care Excellence recommends clearing the common bile duct surgically during surgery or through endoscopic intervention before or during gallbladder removal. [53]

For common symptomatic gallstones, laparoscopic gallbladder removal remains the standard radical option. British guidelines explicitly recommend laparoscopic cholecystectomy for patients with symptomatic stones. However, the decision for rare and uncomplicated attacks can be discussed on an individual basis, taking into account the patient's age, pain frequency, surgical risk, and preference. [54]

The most recent data pooled together complement this picture. A 2026 meta-analysis of four randomized trials involving 677 participants showed that cholecystectomy reduced the likelihood of recurrent biliary colic and overall gallstone complications, while a conservative strategy allowed some patients to avoid surgery and associated complications. Therefore, in uncomplicated symptomatic disease, a personalized discussion is possible, but recurrent typical attacks strengthen the case for surgery. [55]

Table 9. Treatment depending on the cause of the attack

Diagnosis	Basic tactics
Uncomplicated biliary colic	Pain relief, prevention of complications, discussion of planned treatment
Recurrent biliary colic	Laparoscopic cholecystectomy is commonly discussed
Acute calculous cholecystitis	Early surgical management in suitable patients
Common bile duct stone	Cleaning the duct
Acute cholangitis	Antimicrobial therapy and restoration of bile flow
Mild biliary pancreatitis	Treatment of pancreatitis and gallbladder removal before discharge
High surgical risk	Individual choice of conservative or drainage methods

Table source: National Institute for Health and Care Excellence, UK. [56]

Can the next attack be prevented?

Diet can reduce the likelihood of symptomatic recurrence in some patients, but it does not remove existing gallstones. Therefore, a person who has completely eliminated pain after dietary changes still carries gallstones unless they have been objectively eliminated or the gallbladder has been removed. [57]

Until definitive treatment is achieved, it's wise to avoid foods that have repeatedly triggered attacks. The UK's National Institute for Health and Care Excellence does not recommend a universal, lifelong low-fat diet, but recommends limiting specific food triggers. [58]

Extremely rapid weight loss can contribute to the development of gallstones, so trying to lose weight rapidly after an attack is not a preventative measure. This is especially true for very low-calorie diets and in some situations following obesity surgery. [59]

Medicinal stone dissolution is not an emergency measure to prevent an imminent attack and is only suitable for a limited group of patients with certain cholesterol stones. Treatment is lengthy, stones may recur, and in the case of recurrent typical biliary pain, laparoscopic cholecystectomy remains a more reliable, radical option for eliminating the source of attacks. [60]

After gallbladder removal, the source of typical gallbladder colic is eliminated, but the surgery does not guarantee the disappearance of all upper abdominal pain. Therefore, it is especially important to confirm before surgery that the symptoms are indeed consistent with biliary pain and not functional dyspepsia, reflux disease, irritable bowel syndrome, or another pathology. [61]

Table 10. Prevention of recurrent attack

Measure	What can you expect from her?
Avoid individual food triggers	May reduce the number of attacks
Moderate balanced diet	Helps control symptoms
Don't lose weight extremely quickly	Reduces the additional risk of stone formation
Be monitored regularly after the first typical attack	Helps to choose treatment in a timely manner
Elective cholecystectomy when indicated	Eliminates the source of cystic attacks
Self-administered "choleretic cleansing"	Not considered evidence-based treatment
Medicinal dissolution	Suitable for certain patients only
Ignoring recurrent attacks	Increases the risk of missing a complication

Table source: National Institute for Health and Care Excellence, UK. [62]

Code according to ICD 10 and ICD 11

The International Classification of Diseases, Tenth Revision, does not have a separate universal diagnosis for "cholelithiasis attack." The code is determined by what specifically caused the attack. For a gallstone without cholecystitis, the category K80.2 is used; for a gallstone with acute cholecystitis, K80.0; for a bile duct stone with cholangitis, K80.3; for a bile duct stone without cholangitis or cholecystitis, K80.5. National clinical modifications of the classification may contain additional numbers, for example, specifying the presence of obstruction. [63]

In the International Classification of Diseases, Eleventh Revision, cholelithiasis is classified as DC11. The 2026 World Health Organization version uses, inter alia, DC11.3 for gallbladder or cystic duct stone without cholecystitis or cholangitis; this category includes biliary colic without cholecystitis. DC11.0 denotes gallbladder or cystic duct stone with acute cholecystitis, DC11.4 bile duct stone with cholangitis, and DC11.6 bile duct stone without cholangitis or cholecystitis. Therefore, coding is based on the final diagnosis rather than the word "attack". [64]

Table 11. Corresponding International Classification of Diseases codes

Clinical situation	Tenth revision	Eleventh Revision
Gallstone disease as a category	K80	DC11
Gallbladder stone without cholecystitis	K80.2	DC11.3
Biliary colic due to a gallstone without inflammation	Usually K80.2	DC11.3
Gallbladder stone with acute cholecystitis	K80.0	DC11.0
Bile duct stone with cholangitis	K80.3	DC11.4
Bile duct stone with cholecystitis	K80.4	DC11.5
Bile duct stone without cholangitis and cholecystitis	K80.5	DC11.6
Cholelithiasis, unspecified	Within the K80 category according to the national version used	DC11.Z

Table source: World Health Organization, International Classification of Diseases, Eleventh Revision, 2026 version. [65]

Source for the structure of the tenth revision. [66]

Practical note: Code K80.2 or DC11.3 should not be automatically assigned simply because a patient reports "biliary colic." Stones must first be confirmed and cholecystitis, common bile duct stones, cholangitis, and pancreatitis must be ruled out.

Key points from experts

Michele Pisano, a surgeon in the Department of General and Emergency Surgery at the Papa Giovanni XXIII Hospital in Bergamo, is the lead author of the updated World Society for Emergency Surgery guidelines on acute calculous cholecystitis. The key practical implication of his international group's guidelines is that acute calculous cholecystitis should be treated differently from simple biliary colic: in most surgically suitable patients, early laparoscopic cholecystectomy is preferable to prolonged waiting. [67]

Kurinchi Gurusami is Professor of Evidence-Based Medicine and Surgery at University College London and Director of Research in the Division of Surgery at the university. He is a co-author of international guidelines on acute cholecystitis; his work emphasizes the need to rely on a systematic analysis of evidence rather than traditional surgical practice alone. This is particularly relevant when deciding between observation and surgery in patients with uncomplicated symptomatic gallstone disease. [68]

Scott Tenner, MD, MPH, JD, is a Fellow of the American College of Gastroenterology and lead author of the 2024 American College of Gastroenterology Guidelines for Acute Pancreatitis. For patients with gallstones, the guideline's principle is particularly important: gallstone pancreatitis should not be treated as just another episode of colic; in mild cases, after stabilization, it is advisable to remove the gallbladder before discharge to reduce the risk of a recurrence. [69]

Stephen Strasberg is a professor of surgery at Washington University in St. Louis, founder of the Section of Hepatobiliary and Pancreatic Surgery, and creator of the internationally accepted Critical View of Safety principle for safe cholecystectomy. His work demonstrates that the goal of surgical treatment is not simply to remove the source of attacks, but also to identify the biliary anatomy as reliably as possible to reduce the risk of injury during surgery. [70]

Masamichi Yokoe is the lead author of the Tokyo International Diagnostic Criteria for Acute Cholecystitis. The system, developed by an international group, is based on an important clinical principle: the diagnosis of acute cholecystitis cannot be reliably made based on pain or Murphy's sign alone. A combination of local signs, a systemic inflammatory response, and imaging data is necessary. [71]

FAQ: Frequently asked questions about gallstone attacks

How can you tell if a gallbladder attack has begun?

Typically, severe pain in the right hypochondrium or upper central abdomen becomes persistent, persisting for tens of minutes or several hours and may radiate to the back or right shoulder blade. Nausea and vomiting are possible. However, diagnosis cannot be made based solely on sensation. [72]

Can an attack start suddenly at night?

Yes. Gallbladder attacks often occur in the evening or at night, including some time after a large meal. [73]

How long can safe biliary colic last?

There is no hard and fast safety limit. A typical attack can last from tens of minutes to several hours, but persistent pain requires medical evaluation, as it is impossible to reliably rule out cholecystitis and other complications at home. [74]

If the pain lasts for six hours, could it still be colic?

Theoretically, it is possible, but such a duration already significantly increases the suspicion of acute cholecystitis or another complication. Continuing severe pain should not simply be waited out at home. [75]

Is it necessary for pain to occur on the right side during an attack?

No. The pain may be located in the epigastrium, that is, in the middle of the upper abdomen. Therefore, the disease is sometimes mistakenly perceived as a stomach problem. [76]

Can the pain radiate to the back?

Yes. Biliary colic may radiate to the back or right shoulder blade. Severe, persistent epigastric pain with pronounced radiating to the back also requires ruling out acute pancreatitis. [77]

Why does vomiting sometimes make you feel better?

Vomiting may be accompanied by intense visceral pain, but its occurrence does not eliminate the stone. A temporary improvement in well-being after vomiting does not confirm that the obstruction in the bile duct has disappeared. [78]

Can an attack go away on its own?

Yes. Biliary colic usually stops once the stone dislodges and no longer blocks the duct. However, this does not mean that the gallstones have disappeared. [79]

If the attack has passed, do I still need to see a doctor?

After the first characteristic attack, it is advisable to undergo a routine medical examination, even if the pain has completely disappeared. Symptomatic stones differ in their management from incidentally discovered asymptomatic stones. [80]

What does fever mean during an attack?

The temperature is atypical for simple biliary colic and raises suspicion of inflammation or infection, primarily acute cholecystitis or cholangitis. [81]

What does jaundice mean?

Yellowing of the skin or the whites of the eyes may indicate that a stone has entered the common bile duct and is blocking the flow of bile. This requires urgent medical evaluation. [82]

Why does urine become dark?

With a severe obstruction of bile flow, bilirubin accumulates in the blood and begins to be excreted in larger quantities through the kidneys, so the urine can become dark brown or tea-colored. [83]

Do I need to take antibiotics for every attack?

No. Uncomplicated biliary colic is primarily a mechanical obstruction, not a bacterial infection. Antibiotics are used when there are appropriate signs of an infectious or inflammatory complication and are prescribed according to clinical indications. [84]

Can I use an antispasmodic?

Antispasmodic drugs may reduce symptoms but do not eliminate the stone. Systematic data show a more convincing analgesic effect of nonsteroidal anti-inflammatory drugs, although the choice of drug should take into account the contraindications of the individual patient. [85]

Does a heating pad help?

Heat does not remove the stone or reliably restore bile flow. The main danger lies not so much in the heating pad itself, but in attempting to treat hours-long pain at home, thereby delaying the diagnosis of cholecystitis, cholangitis, or pancreatitis. [86]

Is it possible to eat during a severe attack?

A large meal can stimulate gallbladder contractions, so it's unwise to continue heavy meals during severe biliary pain. If symptoms persist and a trip to the hospital is required, the medical team will determine the next dietary regimen, taking into account any procedure or surgery. [87]

Are large or small stones more dangerous?

Size alone does not determine the risk of all complications. Small stones migrate more easily from the gallbladder into the common bile duct and therefore have the potential to cause choledocholithiasis or pancreatitis; larger stones can cause other problems. Individual risk is determined by the overall clinical picture. [88]

Is it possible to dissolve a stone immediately after an attack?

There is no quick, medicinal way to dissolve a stone within hours or days. Medication-based dissolution is only suitable for certain types of stones and requires long-term treatment; it is not an emergency treatment for biliary colic. [89]

After how many attacks is it necessary to remove the gallbladder?

There is no universal definition of "three attacks" or "five attacks." Current guidelines recommend cholecystectomy for confirmed symptomatic stones, but in the case of a single, uncomplicated colic episode, the decision can be individualized. Recurring, typical attacks enhance the benefit of radical treatment. [90]

What does the latest data from 2026 show about the operation?

An updated meta-analysis from 2026 shows that cholecystectomy is more effective than conservative observation in reducing recurrent biliary colic and overall complications. However, some patients with uncomplicated disease may avoid surgery with a conservative strategy, so the decision in the absence of complications should take into account individual risks and preferences. [91]

The main thing about an attack of gallstone disease

An attack occurs primarily when a stone temporarily or permanently obstructs the flow of bile. Typical biliary colic presents as intense pain in the right hypochondrium or epigastrium, which, after increasing, becomes relatively constant and can last for several hours. [92]

Cessation of pain does not mean the stones have disappeared. It often simply indicates that the stone has stopped blocking the cystic duct. After the initial attack, further episodes are possible, so symptomatic gallstone disease requires medical evaluation. [93]

Fever, chills, jaundice, dark urine, light-colored stools, persistent pain, and repeated vomiting are reasons to rule out acute cholecystitis, common bile duct stones, cholangitis, and pancreatitis. These conditions cannot be safely diagnosed based solely on symptoms at home. [94]

The primary initial imaging test remains ultrasound, supplemented by laboratory tests. If a common bile duct stone is suspected, magnetic resonance imaging (MRI) or endoscopic ultrasound (EUS) may be required.[95]

Laparoscopic gallbladder removal remains the mainstay of definitive treatment for confirmed symptomatic gallstone disease. The most recent systematic review from 2026 confirms that surgery reduces recurrent biliary pain and the overall risk of stone-related complications, although conservative observation may be considered in carefully selected uncomplicated cases. [96]