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Emergency and Acute Medicine – Cholelithiasis
Overview and mechanism
Cholelithiasis refers to the presence of gallstones that become symptomatic when they obstruct the cystic duct or common bile duct, disrupting normal bile flow and triggering gallbladder spasm. This produces the characteristic pain of biliary colic. A related functional disorder, biliary dyskinesia, causes identical symptoms despite the absence of stones. When stones migrate into the common bile duct (choledocholithiasis), pain may be more prolonged and is often accompanied by abnormal liver function tests and bilirubin elevation, with risk of complications such as cholangitis or pancreatitis.
Causes and risk factors
Most gallstones are cholesterol stones, which develop when bile becomes supersaturated with cholesterol. Pigment stones account for about one fifth of cases and consist mainly of calcium bilirubinate; they are commonly associated with hemolytic disorders that increase unconjugated bilirubin levels. The incidence of gallstones rises with age and is higher in females, with additional risk factors including obesity, pregnancy, rapid weight loss, Hispanic ethnicity, and medications that promote biliary stasis such as oral contraceptives or ceftriaxone. In children, gallstones are rare and are usually linked to hemolytic anemias such as sickle cell disease or hereditary spherocytosis. Biliary sludge, a nonstone crystalline material, may also cause biliary colic and is associated with pregnancy, rapid weight loss, certain medications, and organ transplantation. Chronic obstruction with calcium deposition can lead to a porcelain gallbladder, a condition associated with an increased risk of gallbladder carcinoma.
Clinical presentation
Patients typically describe dull, aching epigastric or right upper quadrant pain that develops gradually over several minutes, persists for 30 minutes to several hours, and then resolves. The pain often radiates to the right scapula, shoulder, or thoracic spine and is frequently triggered by a large or fatty meal. Associated symptoms include anorexia, nausea, and vomiting. Patients are usually afebrile; the presence of fever or chills suggests a complication such as cholecystitis or cholangitis.
Examination findings
On examination, there is tenderness to deep palpation in the right upper quadrant without rebound or guarding. A Murphy sign may be present during an active episode of biliary colic but should resolve once the pain subsides.
Initial evaluation
Assessment includes exclusion of cardiac causes when appropriate, along with basic laboratory testing such as a complete blood count, liver function tests, pancreatic enzymes, urinalysis, and pregnancy testing when indicated. These tests help distinguish uncomplicated biliary colic from complications involving infection, obstruction, or pancreatitis.
Diagnostic studies
Laboratory studies are often normal in uncomplicated cholelithiasis. Leukocytosis or significant liver enzyme abnormalities suggest cholecystitis, cholangitis, or common bile duct obstruction. Ultrasound is the imaging modality of choice, with high sensitivity and specificity for gallstones and the ability to assess bile duct dilation and gallbladder wall changes. Hepatobiliary scintigraphy is useful when cholecystitis is suspected but ultrasound findings are equivocal, though it does not directly visualize stones. Computed tomography is less sensitive for gallstones but may identify complications or alternative diagnoses.
Differential considerations
Conditions that can mimic biliary colic include myocardial infarction, abdominal aortic aneurysm, acute cholecystitis, cholangitis, pancreatitis, renal colic, peptic ulcer disease, pneumonia involving the right lower lobe, hepatitis, and other intra-abdominal emergencies.
Early management
Initial treatment focuses on supportive care. Intravenous access and fluids are provided for patients with vomiting or dehydration, and oral intake is withheld during acute symptoms. Pain control is essential, often with parenteral nonsteroidal anti-inflammatory drugs or opioids combined with antiemetics once the diagnosis is reasonably secure.
Emergency department care
Hydration, analgesia, and antiemetics form the mainstay of treatment for uncomplicated biliary colic. Anticholinergic agents have not demonstrated benefit. Ongoing reassessment is required to ensure symptoms resolve and that no complications develop.
Disposition and follow-up
Patients should be admitted and receive surgical or gastroenterology consultation if there is evidence of cholecystitis, cholangitis, common bile duct obstruction, or gallstone pancreatitis. Discharge may be considered when pain has fully resolved, laboratory and imaging studies show no complications, and the patient can tolerate oral intake. All patients with symptomatic gallstones require referral for surgical evaluation, and those with choledocholithiasis need gastroenterology follow-up.
Clinical pearls
Gallstones detected incidentally on imaging may not be the cause of abdominal pain, so alternative diagnoses must always be considered. Ultrasound is the most accurate initial test for gallstones, while hepatobiliary scintigraphy is particularly useful for diagnosing cystic duct obstruction and acute cholecystitis. Computed tomography may miss non-radiopaque stones and should not be relied upon alone for diagnosis.
Overview and mechanism
Cholelithiasis refers to the presence of gallstones that become symptomatic when they obstruct the cystic duct or common bile duct, disrupting normal bile flow and triggering gallbladder spasm. This produces the characteristic pain of biliary colic. A related functional disorder, biliary dyskinesia, causes identical symptoms despite the absence of stones. When stones migrate into the common bile duct (choledocholithiasis), pain may be more prolonged and is often accompanied by abnormal liver function tests and bilirubin elevation, with risk of complications such as cholangitis or pancreatitis.
Causes and risk factors
Most gallstones are cholesterol stones, which develop when bile becomes supersaturated with cholesterol. Pigment stones account for about one fifth of cases and consist mainly of calcium bilirubinate; they are commonly associated with hemolytic disorders that increase unconjugated bilirubin levels. The incidence of gallstones rises with age and is higher in females, with additional risk factors including obesity, pregnancy, rapid weight loss, Hispanic ethnicity, and medications that promote biliary stasis such as oral contraceptives or ceftriaxone. In children, gallstones are rare and are usually linked to hemolytic anemias such as sickle cell disease or hereditary spherocytosis. Biliary sludge, a nonstone crystalline material, may also cause biliary colic and is associated with pregnancy, rapid weight loss, certain medications, and organ transplantation. Chronic obstruction with calcium deposition can lead to a porcelain gallbladder, a condition associated with an increased risk of gallbladder carcinoma.
Clinical presentation
Patients typically describe dull, aching epigastric or right upper quadrant pain that develops gradually over several minutes, persists for 30 minutes to several hours, and then resolves. The pain often radiates to the right scapula, shoulder, or thoracic spine and is frequently triggered by a large or fatty meal. Associated symptoms include anorexia, nausea, and vomiting. Patients are usually afebrile; the presence of fever or chills suggests a complication such as cholecystitis or cholangitis.
Examination findings
On examination, there is tenderness to deep palpation in the right upper quadrant without rebound or guarding. A Murphy sign may be present during an active episode of biliary colic but should resolve once the pain subsides.
Initial evaluation
Assessment includes exclusion of cardiac causes when appropriate, along with basic laboratory testing such as a complete blood count, liver function tests, pancreatic enzymes, urinalysis, and pregnancy testing when indicated. These tests help distinguish uncomplicated biliary colic from complications involving infection, obstruction, or pancreatitis.
Diagnostic studies
Laboratory studies are often normal in uncomplicated cholelithiasis. Leukocytosis or significant liver enzyme abnormalities suggest cholecystitis, cholangitis, or common bile duct obstruction. Ultrasound is the imaging modality of choice, with high sensitivity and specificity for gallstones and the ability to assess bile duct dilation and gallbladder wall changes. Hepatobiliary scintigraphy is useful when cholecystitis is suspected but ultrasound findings are equivocal, though it does not directly visualize stones. Computed tomography is less sensitive for gallstones but may identify complications or alternative diagnoses.
Differential considerations
Conditions that can mimic biliary colic include myocardial infarction, abdominal aortic aneurysm, acute cholecystitis, cholangitis, pancreatitis, renal colic, peptic ulcer disease, pneumonia involving the right lower lobe, hepatitis, and other intra-abdominal emergencies.
Early management
Initial treatment focuses on supportive care. Intravenous access and fluids are provided for patients with vomiting or dehydration, and oral intake is withheld during acute symptoms. Pain control is essential, often with parenteral nonsteroidal anti-inflammatory drugs or opioids combined with antiemetics once the diagnosis is reasonably secure.
Emergency department care
Hydration, analgesia, and antiemetics form the mainstay of treatment for uncomplicated biliary colic. Anticholinergic agents have not demonstrated benefit. Ongoing reassessment is required to ensure symptoms resolve and that no complications develop.
Disposition and follow-up
Patients should be admitted and receive surgical or gastroenterology consultation if there is evidence of cholecystitis, cholangitis, common bile duct obstruction, or gallstone pancreatitis. Discharge may be considered when pain has fully resolved, laboratory and imaging studies show no complications, and the patient can tolerate oral intake. All patients with symptomatic gallstones require referral for surgical evaluation, and those with choledocholithiasis need gastroenterology follow-up.
Clinical pearls
Gallstones detected incidentally on imaging may not be the cause of abdominal pain, so alternative diagnoses must always be considered. Ultrasound is the most accurate initial test for gallstones, while hepatobiliary scintigraphy is particularly useful for diagnosing cystic duct obstruction and acute cholecystitis. Computed tomography may miss non-radiopaque stones and should not be relied upon alone for diagnosis.
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