FFinalistSouthampton · 2027
Gastroenterology
AKT · Gastroenterology/Pancreatobiliary

Gallstones & biliary colic

Cholelithiasis (cholesterol/pigment stones) ± transient cystic-duct obstruction

Overview

Stones in the gallbladder (cholesterol — the '5 Fs': fat, female, forty, fertile, family; or pigment — haemolysis). Most are asymptomatic. BILIARY COLIC = a stone transiently obstructing the cystic duct/Hartmann's pouch → episodic RUQ/epigastric pain (post-fatty-meal, no fever/inflammation). The complications form a family: cholecystitis, cholangitis, gallstone pancreatitis, obstructive jaundice, gallstone ileus. Symptomatic stones → laparoscopic cholecystectomy.

Recognise

  • BILIARY COLIC: episodic, constant RUQ/epigastric pain radiating to the right scapula, lasting <6 hours, often after a fatty meal, with nausea — but NO fever and NORMAL inflammatory markers
  • Risk factors: female, forty, fat, fertile, family history; pigment stones with haemolysis
  • Asymptomatic in most; ultrasound shows gallstones ± a thickened wall

Red flags

  • Fever + RUQ pain + raised inflammatory markers → cholecystitis (inflammation), not simple colic
  • Jaundice + abnormal LFTs → CBD stone/obstruction (± cholangitis) — urgent
  • Epigastric pain + raised amylase → gallstone pancreatitis

Differentials & how to tell them apart

Acute cholecystitispersistent pain + FEVER + Murphy positive + raised inflammatory markers (inflammation, not just colic)
Acute cholangitisCharcot triad (RUQ pain + fever + jaundice) — CBD stone + infection
Peptic ulcer/GORDepigastric, meal-related, no gallstones
Acute pancreatitisepigastric pain to back + raised amylase/lipase
Gallstone on ultrasound — echogenic focus with posterior acoustic shadowing

Gallstone on ultrasound — echogenic focus with posterior acoustic shadowing

James Heilman, MD / CC BY-SA 3.0 — Wikimedia Commons

Investigations

ULTRASOUND (gallstones, wall thickness, duct dilatation); LFTs (cholestatic if CBD stone); amylase/lipase (exclude pancreatitis); MRCP for suspected CBD stones.

Management

Analgesia + laparoscopic cholecystectomy for symptomatic gallstones

  1. 1Confirm gallstones on ultrasound and check LFTs/amylase. Manage the colic episode with analgesia; refer symptomatic gallstones for laparoscopic cholecystectomy.Gate: Distinguish simple biliary COLIC (no fever, normal inflammatory markers, normal LFTs) from its COMPLICATIONS — fever (cholecystitis), jaundice + abnormal LFTs (CBD stone/cholangitis), raised amylase (gallstone pancreatitis) — each escalates management
  2. 2Laparoscopic cholecystectomy; ERCP/bile-duct clearance for CBD stones; manage complications (cholecystitis/cholangitis/pancreatitis).
Analgesia (NSAID/diclofenac or opioid) — for the colic episode
Laparoscopic cholecystectomy — definitive for symptomatic gallstones; early (within 1 week) for acute cholecystitis

Key points

Episodic post-fatty-meal RUQ pain (<6 h) + gallstones + NO fever/normal bloods = biliary colic → analgesia + lap chole. Fever = cholecystitis; jaundice + fever = cholangitis; raised amylase = gallstone pancreatitis. The whole complication family hangs off the stone.

Monitor & prognosis

Symptoms; complications; pre-op LFTs.

Excellent after cholecystectomy.

Source: NICE CG188; CKS Gallstones