Gallstones in the gallbladder; transient cystic duct obstruction causes episodic RUQ pain.
Also known as: cholelithiasis, gallstones, biliary colic, symptomatic gallstone disease
Overview
Cholelithiasis: presence of gallstones in the gallbladder. Biliary colic: episodic RUQ or epigastric pain caused by transient obstruction of the cystic duct by a gallstone, without inflammation or infection.
Epidemiology
Gallstones present in ~10-15% of US adults; ~80% lifetime asymptomatic. Annual risk of biliary symptoms in asymptomatic patients ~1-4%/year. Female predominance, especially in childbearing years.
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Question 1GastrointestinalMedium
A 54-year-old woman presents with a 6-month history of recurrent episodes of dull right upper quadrant pain after eating fatty meals, each lasting 1–2 hours and resolving spontaneously. She has nausea but no fever, jaundice, or weight loss. She has had at least four similar episodes. On examination, she is afebrile with mild RUQ tenderness and no Murphy sign. WBC, liver enzymes, lipase, and bilirubin are all normal. Right upper quadrant ultrasound shows a thick-walled, contracted gallbladder with multiple gallstones and no pericholecystic fluid. Which of the following is the most likely diagnosis?
ACholedocholithiasis
BAcute cholecystitis
CChronic cholecystitis
DChronic pancreatitis
ESphincter of Oddi dysfunction
Reveal answer & full explanation
Correct answer: C — Chronic cholecystitis
ACholedocholithiasis
BAcute cholecystitis
CChronic cholecystitis✓
DChronic pancreatitis
ESphincter of Oddi dysfunction
Why chronic cholecystitis is correct
Chronic cholecystitis is persistent low-grade inflammation of the gallbladder, almost always due to chronic mechanical irritation from cholelithiasis.
Patients present with recurrent episodes of biliary colic — postprandial right upper quadrant (RUQ) pain after fatty meals — without the fever, leukocytosis, or sustained pain that define acute cholecystitis.
Ultrasound classically shows gallstones with gallbladder wall thickening and a contracted, fibrotic gallbladder, but no pericholecystic fluid and a negative sonographic Murphy sign — exactly as in this patient.
Why the others are wrong
Acute cholecystitis — requires sustained pain, fever, leukocytosis, and sonographic findings of pericholecystic fluid or a positive sonographic Murphy sign; none of these are present.
Choledocholithiasis — would produce elevated bilirubin and alkaline phosphatase with a dilated common bile duct; labs are normal here.
Sphincter of Oddi dysfunction — is diagnosed in patients with biliary pain after cholecystectomy, typically with transient transaminase or alkaline phosphatase elevations and a dilated common bile duct; this patient has an intact stone-filled gallbladder and entirely normal liver chemistries.
Chronic pancreatitis — tempting because recurrent postprandial pain with a normal lipase can occur once the pancreas is fibrosed, but that pain is typically epigastric and radiates to the back, and it most often follows heavy alcohol use; this ultrasound localizes the disease to a stone-filled, thick-walled, contracted gallbladder.
Question 2GastrointestinalEasy
A 42-year-old woman presents with recurrent episodes of right upper quadrant pain lasting 30-60 minutes, especially after fatty meals. Ultrasound shows multiple gallstones with acoustic shadowing. No fever, no leukocytosis. Total bilirubin is normal. What is the most appropriate management?
AERCP followed by cholecystectomy
BElective laparoscopic cholecystectomy
CEmergent cholecystectomy
DUrsodeoxycholic acid
ELow-fat diet and observation
Reveal answer & full explanation
Correct answer: B — Elective laparoscopic cholecystectomy
AERCP followed by cholecystectomy
BElective laparoscopic cholecystectomy✓
CEmergent cholecystectomy
DUrsodeoxycholic acid
ELow-fat diet and observation
Why Elective laparoscopic cholecystectomy is correct
This is symptomatic cholelithiasis (biliary colic): episodic right upper quadrant (RUQ) pain after fatty meals, no fever, normal labs, and gallstones on ultrasound
Elective laparoscopic cholecystectomy is the treatment of choice
Why the others are wrong
ERCP followed by cholecystectomy — choledocholithiasis (common bile duct stones with elevated bilirubin and alkaline phosphatase) is managed with ERCP then cholecystectomy; bilirubin is normal here
Emergent cholecystectomy — acute cholecystitis (Murphy sign, fever, leukocytosis) would warrant urgent cholecystectomy; those features are absent here
Ursodeoxycholic acid — oral bile-acid dissolution works only on small radiolucent cholesterol stones, takes months, and stones often recur after it is stopped; it is reserved for patients who are unfit for or decline surgery, not a healthy surgical candidate with biliary colic (its main hepatology indication is primary biliary cholangitis, not primary sclerosing cholangitis)
Low-fat diet and observation — her attacks follow fatty meals, so avoiding dietary fat can seem like logical first-line care, but diet does not remove the stones, and with recurrent biliary colic she remains at risk of further attacks and of complications such as acute cholecystitis, choledocholithiasis and gallstone pancreatitis; expectant management is the approach for asymptomatic gallstones, not for a healthy surgical candidate with symptoms
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Cholesterol stones (75% in Western countries): 4 F's — Female, Fat (obesity), Forty, Fertile (pregnancy/OCP); also rapid weight loss, total parenteral nutrition, Native American ethnicity (Pima), Crohn disease (terminal ileum — bile salt malabsorption)
Analgesia (NSAIDs preferred — also reduce risk of progression to cholecystitis)
Antiemetics
Dietary advice — low-fat diet may reduce attacks while awaiting surgery
Second-line / adjunct
Prophylactic cholecystectomy for asymptomatic stones in selected high-risk groups: porcelain gallbladder (cancer risk), large stones >3 cm, gallbladder polyps >1 cm, hereditary spherocytosis or sickle cell during splenectomy, transplant candidates
Oral bile acid dissolution (ursodeoxycholic acid) — limited efficacy, high recurrence; reserved for patients unfit for surgery
Extracorporeal shock wave lithotripsy — rarely used
ERCP with sphincterotomy and stone extraction for retained CBD stones
Complications
Progression to acute cholecystitis (most common complication of symptomatic gallstones)
Choledocholithiasis — stone in CBD
Ascending cholangitis
Gallstone pancreatitis
Mirizzi syndrome
Gallstone ileus (mechanical SBO from large stone via cholecystoenteric fistula)
Gallbladder cancer — porcelain gallbladder, large stones, polyps >1 cm, primary sclerosing cholangitis
PANCE pearls
Asymptomatic gallstones do NOT warrant cholecystectomy in most patients — annual risk of symptoms is low.
Indications for prophylactic cholecystectomy in asymptomatic disease: porcelain gallbladder, polyps >1 cm, stones >3 cm, sickle cell or hereditary spherocytosis (concurrent with splenectomy), transplant candidates.
Biliary colic resolves within 6 h — sustained pain beyond 6 h with fever/leukocytosis = acute cholecystitis.
RUQ ultrasound is first-line — sensitive, specific, no radiation, low cost.
MRCP and EUS are most sensitive for CBD stones when ultrasound is non-diagnostic.
Functional gallbladder disorder (biliary dyskinesia): typical biliary pain, no stones, HIDA EF <35% — cholecystectomy can help selected patients but outcomes variable.
Cholesterol stones predominate in Western populations; pigment stones in Asian populations and in hemolytic anemias.
Sickle cell patients should have cholecystectomy at time of splenectomy due to high pigment stone burden.
Pregnancy: cholecystectomy preferred in second trimester if symptomatic; conservative management with low-fat diet for mild attacks.
Ursodeoxycholic acid reduces stone formation during rapid weight loss after bariatric surgery.
References
ASGE 2019 — ASGE Standards of Practice Committee; Buxbaum JL, Abbas Fehmi SM, Sultan S, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc 2019;89:1075-1105.e15
EASL 2016 — European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol 2016;65:146-181
SAGES 2010 — Overby DW et al. SAGES Guidelines for the Clinical Application of Laparoscopic Biliary Tract Surgery. Surg Endosc 2010;24:2368-2386
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