Upper GI & Hepatobiliary Surgery

Gallstones and Biliary Colic

Gallstones are often silent; when a stone transiently obstructs the cystic duct, it causes biliary colic, while persistent or downstream obstruction produces cholecystitis, jaundice, cholangitis or pancreatitis.

In a nutshell

Gallstones cause symptoms when they obstruct a duct. Transient cystic-duct obstruction causes biliary colic: episodic RUQ or epigastric pain without systemic inflammation. Persistent pain, fever, jaundice or severe epigastric pain indicates a complication. Use LFTs and ultrasound first, offer lap chole for symptomatic stones, and use MRCP/EUS then ERCP or surgical clearance when a common-bile-duct stone is suspected.

Classic presentation

Self-limiting biliary-type right-upper-quadrant or epigastric pain, often after food and radiating to the back or shoulder, without fever, peritonism or shock.

Key points

Most gallstones are silent. Incidental gallstones in a normal gallbladder and normal biliary tree do not need routine treatment.
Biliary colic is transient cystic-duct obstruction; persistent pain, fever or Murphy sign should prompt assessment for acute cholecystitis.
Jaundice, dark urine, pale stools or a cholestatic liver-test pattern suggests a common-bile-duct stone, not uncomplicated colic.
Use ultrasound and LFTs first. If the duct is dilated or LFTs are abnormal without a duct stone on ultrasound, consider MRCP and EUS if MRCP is non-diagnostic.
Offer laparoscopic cholecystectomy for symptomatic gallstones; do not use repeated analgesia alone as definitive management for recurrent attacks.
If a common-bile-duct stone is confirmed, clear the duct with ERCP or surgery before or at cholecystectomy; a stent is temporary if ERCP cannot clear it.
Use current BNF and local guidance for analgesic choice and dosing. NSAIDs may be suitable but require renal, gastrointestinal, bleeding, pregnancy and allergy assessment.

First-line investigation

Liver-function tests and transabdominal ultrasound; use MRCP or EUS when a common-bile-duct stone is suspected but not seen on ultrasound.

Management

Relieve pain safely

Offer analgesia and antiemetics; consider an NSAID when appropriate, use alternatives when contraindicated, and check current BNF/local guidance for dosing and safety.^2,3,4,5

Confirm and stage

Use LFTs and ultrasound first. If persistent pain, fever, jaundice or systemic illness is present, switch to the appropriate cholecystitis, cholangitis, pancreatitis or acute-abdomen pathway.^1,2

Treat symptomatic gallbladder stones definitively

Offer laparoscopic cholecystectomy for symptomatic gallstones; do not routinely treat incidentally found asymptomatic stones in a normal gallbladder and biliary tree.¹

Clear common-bile-duct stones

Use MRCP or EUS for suspected duct stones, then clear confirmed stones with ERCP or surgery before or at cholecystectomy; treat stenting as temporary until definitive clearance.¹

Safety-net and prevent recurrence

Give urgent return advice for persistent pain, fever, jaundice, rigors, vomiting, confusion or collapse, and ensure surgical follow-up for recurrent symptomatic disease.^2,6,1

Exam traps

Gallstones on ultrasound may be incidental; match them to a typical biliary history and exclude other causes of pain.
Normal inflammatory markers support uncomplicated colic but do not rule out every complication, particularly if symptoms are evolving.
Fever or persistent pain is not simple colic: assess for acute cholecystitis or another acute abdomen.
Jaundice suggests common-bile-duct disease; use MRCP/EUS and an ERCP or surgical clearance pathway rather than routine elective cholecystectomy alone.
ERCP is therapeutic duct clearance, not the first diagnostic test for stable suspected choledocholithiasis.
Do not offer routine surgery for asymptomatic stones in a normal gallbladder and biliary tree.
Avoid prescribing NSAIDs without checking renal function, ulcer/bleeding risk, pregnancy and other contraindications.

Illustrations

Gallstones in a surgical specimenMultiple faceted gallstones removed at cholecystectomy.George Chernilevsky, Wikimedia Commons · CC-BY-SA-4.0

Laparoscopic cholecystectomy for symptomatic gallstonesIntraoperative image of laparoscopic ports and dissection of Calot's triangle during gallbladder removal.Xawaari, Wikimedia Commons · CC-BY-SA-4.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.