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.

Definition

Gallstones are solid concretions of cholesterol, pigment or mixed material that form in the gallbladder. Most are asymptomatic; symptomatic stones can cause biliary colic, cholecystitis, common-bile-duct obstruction, cholangitis or gallstone pancreatitis.

Epidemiology

Gallstones are common in adults and risk rises with age, obesity, rapid weight change, pregnancy, oestrogen exposure, family history, ileal disease and chronic haemolysis. Most people with gallstones never develop symptoms.

Pathophysiology

Cholesterol or pigment precipitates within bile and grows in the gallbladder. Transient obstruction of the cystic duct during gallbladder contraction raises pressure and causes biliary pain; persistent cystic-duct obstruction inflames the gallbladder. Migration into the common bile duct can produce obstructive jaundice, cholangitis or pancreatitis.

First principles

Most stones are an anatomical finding, not a disease

Gallstones form from cholesterol, pigment or mixed material within the gallbladder, but many never obstruct a duct and cause no symptoms. NICE advises no treatment for incidentally found stones when the gallbladder and biliary tree are normal and the person is asymptomatic.^1,2

Transient obstruction causes biliary colic

A stone temporarily impacts at the gallbladder neck or cystic duct while the gallbladder contracts. Pressure produces episodic right-upper-quadrant or epigastric pain, often after a meal, but the obstruction releases and the gallbladder wall is not persistently inflamed. Pain that becomes constant or systemic features develop suggests a complication instead.^2,1

Pain location is less important than the time course and associated features

Biliary pain may be epigastric or right upper quadrant and can radiate to the back or shoulder. The high-yield distinction is a self-limiting attack without sepsis or peritonism versus persistent pain, fever, jaundice or organ dysfunction, which requires assessment for cholecystitis, cholangitis, pancreatitis or another acute abdomen.^2,1

A stone can move from the gallbladder into the common bile duct

A duct stone may cause transient or persistent cholestasis, ascending cholangitis or gallstone pancreatitis. Liver tests and ultrasound help identify this branch; if the duct is dilated or liver tests are abnormal without a visible stone, NICE recommends MRCP and then EUS if MRCP is non-diagnostic.¹

Presentation

Episodes of right-upper-quadrant or epigastric biliary pain, often after food and sometimes radiating to the back or right shoulder, with nausea or vomiting. Uncomplicated biliary colic should settle without fever, peritonism or systemic deterioration.^1,2

Cardinal features

Biliary-type right-upper-quadrant or epigastric pain
Pain may follow a meal and radiate to the back or right shoulder
Nausea or vomiting during an episode
No persistent fever, peritonism or shock in uncomplicated colic
Gallstones on ultrasound with no inflammatory gallbladder or duct complication
Recurrent symptoms or complications from symptomatic gallstones

Red flags

Pain that persists or becomes constant, fever or Murphy sign suggesting acute cholecystitis
Jaundice, dark urine, pale stools or cholestatic liver tests suggesting common-bile-duct obstruction
Rigors, hypotension, confusion or organ dysfunction suggesting ascending cholangitis
Severe epigastric pain radiating to the back or raised pancreatic enzymes suggesting gallstone pancreatitis
Peritonism, shock or gastrointestinal obstruction suggesting perforation, another acute abdomen or gallstone ileus
Persistent or atypical pain despite no explanatory gallstone finding

Investigations

Transabdominal ultrasound

Use ultrasound as the first-line imaging test for suspected gallstone disease. It identifies gallstones and can assess gallbladder inflammation, duct dilatation and other upper-abdominal pathology.

Expected finding: Mobile echogenic stones with posterior shadowing in the gallbladder, without the inflammatory changes or duct obstruction expected in a complication.

^1,2

Liver-function tests

Check liver tests with ultrasound. Significant cholestatic abnormality, jaundice or a dilated duct should prompt investigation for a common-bile-duct stone rather than labelling the episode simple biliary colic.

Expected finding: Liver tests may be normal in uncomplicated colic; a cholestatic pattern or bilirubin rise suggests duct obstruction, although a transient stone can cause changing results.

FBC, CRP, renal function and pancreatic enzymes when indicated

Use inflammatory markers and organ-function tests when the presentation is persistent, atypical or systemically unwell. Check pancreatic enzymes when severe epigastric pain or a pancreatitis pathway is suspected.

Expected finding: Raised inflammatory markers suggest cholecystitis or cholangitis; renal dysfunction indicates severity; raised pancreatic enzymes support gallstone pancreatitis.

^2,1

MRCP or endoscopic ultrasound for suspected duct stones

If ultrasound has not detected a common-bile-duct stone but the duct is dilated or liver tests are abnormal, consider MRCP. If MRCP is non-diagnostic, consider EUS. ERCP is a therapeutic clearance procedure, not a routine diagnostic test.

Expected finding: A filling defect, stricture or dilated duct requiring a bile-duct-clearance plan.

Management

Step	Detail	Source
Treat the acute biliary-pain episode safely	Offer analgesia and antiemetic treatment. Consider an NSAID when suitable; use paracetamol or an opioid when an NSAID is contraindicated or insufficient, with current BNF and local guidance for agent, dose, renal function, bleeding risk and interactions. Avoid food and drink that trigger symptoms while awaiting definitive assessment or surgery.^2,1,3,4,5	NICE CKS Gallstones, NICE CG188 and current BNF monographs
Confirm gallstone disease and look for complications	Offer liver-function tests and transabdominal ultrasound. If pain is persistent, fever, jaundice or systemic illness is present, investigate and manage the relevant cholecystitis, cholangitis, pancreatitis or acute-abdomen pathway rather than treating this as outpatient colic.^1,2	NICE CG188 and NICE CKS Gallstones
Do not treat asymptomatic gallbladder stones routinely	Reassure people with incidentally detected gallbladder stones when the gallbladder and biliary tree are normal and they have no symptoms. Document exceptions or specialist indications rather than offering prophylactic cholecystectomy as routine treatment.¹	NICE CG188 recommendation 1.2.1
Offer laparoscopic cholecystectomy for symptomatic gallstones	Offer laparoscopic cholecystectomy to people diagnosed with symptomatic gallbladder stones. Day-case surgery may be appropriate for an elective procedure unless the person's condition or circumstances require admission. Explain that removing the gallbladder is definitive treatment for recurrent symptomatic gallbladder stones, but does not by itself clear a common-bile-duct stone.^1,2	NICE CG188 recommendations 1.2.2 and 1.2.3
Clear common-bile-duct stones through the correct pathway	If MRCP, EUS or other imaging confirms common-bile-duct stones, arrange duct clearance surgically at laparoscopic cholecystectomy or with ERCP before or at surgery. If ERCP cannot clear the duct, use biliary stenting only as a temporary drainage measure until definitive endoscopic or surgical clearance.¹	NICE CG188 recommendations 1.3.1 to 1.3.4
Safety-net and reassess atypical symptoms	Advise urgent review for constant or worsening pain, fever, jaundice, rigors, vomiting, confusion, collapse, pale stools/dark urine or inability to tolerate fluids. Reassess if symptoms persist without a clear biliary explanation; gallstones may be incidental and not the cause of pain.^2,6	NICE CKS Gallstones and NHS gallstones information

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

Differentials

Peptic ulcer disease or dyspepsia

Epigastric symptoms with an acid-related history and no biliary or systemic features.

Acute cholecystitis

Persistent right-upper-quadrant pain, fever, local inflammation or Murphy sign rather than self-limiting colic.

Ascending cholangitis

Fever or rigors with jaundice, cholestatic obstruction or organ dysfunction.

Gallstone pancreatitis

Severe epigastric pain radiating to the back with compatible pancreatic enzyme or imaging findings.

Acute coronary syndrome or right-lower-lobe pneumonia

Cardiac or respiratory symptoms and abnormal ECG, troponin or chest imaging.

Right renal colic

Loin-to-groin pain, urinary symptoms or haematuria rather than biliary pain.

Complications

Acute cholecystitis and gallbladder empyema
Obstructive jaundice and ascending cholangitis
Gallstone pancreatitis
Mirizzi syndrome and gallstone ileus
Recurrent biliary pain and emergency admissions
Rare gallbladder malignancy association

Prognosis

Asymptomatic stones usually remain untreated. Symptomatic gallbladder stones generally have a good outcome after laparoscopic cholecystectomy, while duct obstruction, cholangitis and pancreatitis carry greater morbidity and need separate urgent pathways.

Guidelines

Gallstone disease: diagnosis and management (CG188) (NICE, 2014)
Gallstones clinical knowledge summary (NICE CKS, 2024)

References

Evidence checked: 2026-08-03

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.