Gastrointestinal · PANCE / PANRE

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

Spectrum of gallstone disease — distinguishing biliary colic from complicated presentations.

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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