Cholelithiasis and Biliary Colic
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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Risk factors
- 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)
- Pigment stones (black — chronic hemolysis: sickle cell, hereditary spherocytosis, thalassemia, mechanical valve hemolysis; cirrhosis)
- Pigment stones (brown — biliary infection/stasis: parasitic infection in Asia — Clonorchis, Ascaris; biliary stricture)
- Medications: ceftriaxone (biliary sludge), octreotide, fibrates, estrogens
- Diabetes, metabolic syndrome
- Familial predisposition
Pathophysiology
Cholesterol stones: bile supersaturation with cholesterol + gallbladder hypomotility + nucleation factors. Pigment stones: increased unconjugated bilirubin (hemolysis) or biliary stasis/infection precipitates calcium bilirubinate. Biliary colic results when a stone transiently obstructs the cystic duct (during/after gallbladder contraction), causing distension and visceral pain.
Clinical presentation
Symptoms
- Episodic, postprandial (especially after fatty meals) RUQ or epigastric pain
- Pain builds over 15-30 min, plateaus, and resolves within 6 h (typically 1-5 h)
- Radiation to right scapula or interscapular area
- Nausea, vomiting, diaphoresis during episodes
- Pain-free intervals between attacks
- ABSENCE of fever, jaundice, or persistent pain — suggests uncomplicated biliary colic
Signs / physical exam
- Often normal exam between episodes
- Mild RUQ tenderness during attack, but Murphy sign typically NEGATIVE
- No fever
- No jaundice
- Murphy positive + fever or persistent pain → think cholecystitis
Classic findings
Postprandial RUQ pain after fatty meal, lasting 1-5 h, recurrent over weeks to months, with gallstones on US.
Differential diagnosis
- Acute cholecystitis — Sustained pain >6 h, fever, leukocytosis, Murphy sign, US findings of wall thickening/pericholecystic fluid
- Choledocholithiasis — Jaundice, elevated bilirubin, dilated CBD on imaging
- Acute pancreatitis — Epigastric pain to back, lipase >3× ULN
- GERD / peptic ulcer — Burning epigastric pain, relieved by antacids; postprandial similar but no Murphy
- Functional dyspepsia / sphincter of Oddi dysfunction — Recurrent pain without stones; manometry or empiric trial
- Hepatic capsule pain (hepatitis, Fitz-Hugh-Curtis, abscess) — Elevated LFTs, specific findings
- Cardiac (inferior MI, pericarditis) — ECG, troponin in older or atypical presentations
Diagnostic workup
Labs
- CBC, BMP, LFTs — all typically normal in uncomplicated biliary colic
- Lipase — exclude pancreatitis
- Elevated bilirubin or alk phos raises concern for CBD obstruction
Imaging
- RUQ ultrasound — first-line; sensitivity >95% for gallstones >5 mm; identifies gallbladder wall, CBD diameter, signs of cholecystitis
- MRCP — for suspected CBD stones
- EUS — most sensitive for small CBD stones
- HIDA scan — assesses gallbladder ejection fraction; <35% supports symptomatic gallbladder dysmotility (functional gallbladder disorder, biliary dyskinesia)
Diagnostic algorithm
| Feature | Biliary Colic | Acute Cholecystitis | Choledocholithiasis | Cholangitis |
|---|---|---|---|---|
| Pain duration | <6 h, episodic | >6 h, sustained | Variable | Variable |
| Fever | No | Yes | No (unless cholangitis) | Yes |
| Jaundice | No | Rare (mild) | Yes | Yes |
| Murphy sign | Negative | Positive | Negative | Variable |
| LFTs | Normal | Mildly elevated | Elevated bilirubin/alk phos | Markedly elevated |
| US findings | Stones | Stones + wall thickening + pericholecystic fluid | Stones + dilated CBD ≥6 mm | Same + clinical sepsis |
| Definitive Tx | Elective laparoscopic cholecystectomy | Early laparoscopic cholecystectomy | ERCP + cholecystectomy | Emergent ERCP + IV antibiotics |
Treatment
First-line
- Asymptomatic cholelithiasis — observation; NO routine cholecystectomy
- Symptomatic cholelithiasis (biliary colic) — elective laparoscopic cholecystectomy
- 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
- 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
- ACG 2016 — Lee JK et al. ACG Clinical Guideline: Diagnosis and Management of Gallstone Pancreatitis. Am J Gastroenterol 2019;114:1283-1294
- 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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