Overview
Biliary Colic & Acute Cholecystitis
Topic Overview
Summary
Biliary colic is intermittent RUQ pain caused by gallstone temporarily obstructing the cystic duct. Acute cholecystitis is gallbladder inflammation, usually from persistent obstruction. Biliary colic is self-limiting; cholecystitis requires antibiotics and cholecystectomy. Murphy's sign (inspiratory arrest on RUQ palpation) is classic for cholecystitis. Ultrasound is first-line imaging. Early laparoscopic cholecystectomy (within 7 days) is now standard for acute cholecystitis.
Key Facts
- Biliary colic: RUQ pain lasting 30 min-6 hours, no fever, no peritonism
- Cholecystitis: Persistent pain (over 6 hours), fever, Murphy's sign, elevated WCC/CRP
- Imaging: Ultrasound first-line; shows gallstones, wall thickening, pericholecystic fluid
- Treatment: Nil by mouth, analgesia, IV fluids, antibiotics (cholecystitis), cholecystectomy
- Tokyo Guidelines: Severity grading for acute cholecystitis
Clinical Pearls
Pain lasting over 6 hours = suspect cholecystitis, not just colic
Murphy's sign has high specificity for cholecystitis — tender RUQ with inspiratory arrest
USS-negative for stones does NOT exclude biliary disease — 5-10% of stones not seen
Why This Matters Clinically
Gallstone disease is extremely common. Distinguishing biliary colic from cholecystitis determines urgency and treatment. Early surgery reduces complications and length of stay.
Visual Summary
Visual assets to be added:
- Ultrasound showing gallstones with acoustic shadowing
- Murphy's sign demonstration
- Biliary anatomy diagram
- Tokyo Guidelines severity chart
Epidemiology
Prevalence
- Gallstones: 10-15% of Western adults
- Symptomatic gallstones: 1-4% per year of those with stones
- Cholecystectomy: One of the most common elective surgeries
Demographics
- Female > male (2:1)
- Prevalence increases with age
- "5 Fs": Female, Forty, Fertile, Fat, Family history (mnemonic only)
Risk Factors
| Factor | Notes |
|---|---|
| Obesity | Major risk factor |
| Rapid weight loss | Cholesterol supersaturation |
| Pregnancy | Oestrogen effect |
| Diabetes | Gallbladder dysmotility |
| TPN | Biliary stasis |
| Crohn's disease | Reduced bile acid reabsorption |
| Haemolytic disease | Pigment stones |
| Cirrhosis | Pigment stones |
Pathophysiology
Gallstone Formation
- Cholesterol supersaturation in bile
- Nucleation → crystal formation → stone growth
- Pigment stones: Unconjugated bilirubin (haemolysis, cirrhosis)
Biliary Colic
- Gallstone transiently impacts cystic duct
- Gallbladder contracts against obstruction → pain
- Stone dislodges → pain resolves (usually under 6 hours)
Acute Cholecystitis
- Persistent cystic duct obstruction
- Gallbladder distension, mucosal ischaemia
- Secondary bacterial infection (E. coli, Klebsiella, Enterococcus)
- Inflammation → wall thickening, pericholecystic fluid
Complications
| Complication | Mechanism |
|---|---|
| Empyema | Pus-filled gallbladder |
| Gangrene | Wall necrosis |
| Perforation | Free or contained |
| Mirizzi syndrome | Stone compresses CBD |
| Cholangitis | CBD stone + ascending infection |
| Gallstone pancreatitis | Stone impacts ampulla |
Clinical Presentation
Biliary Colic
| Feature | Description |
|---|---|
| Pain | RUQ/epigastric, constant (not truly colicky), 30 min-6 hours |
| Radiation | Back, right scapula |
| Trigger | Fatty meal (not always) |
| Associated | Nausea, vomiting |
| Fever | Absent |
| Tenderness | Mild; no peritonism |
Acute Cholecystitis
| Feature | Description |
|---|---|
| Pain | Persistent over 6 hours |
| Fever | Low-grade or high |
| Murphy's sign | Positive |
| Peritonism | Local RUQ |
| Systemic | Tachycardia, anorexia |
Red Flags
| Finding | Concern |
|---|---|
| Jaundice | CBD stone (choledocholithiasis) |
| Rigors, high fever | Ascending cholangitis |
| Epigastric pain + high amylase | Gallstone pancreatitis |
| Sepsis | Gangrenous/perforated cholecystitis |
Clinical Examination
Vital Signs
- Temperature (fever in cholecystitis)
- Tachycardia (inflammation, sepsis)
Abdominal Examination
- RUQ tenderness
- Murphy's sign: Inspiratory arrest on palpation of RUQ during deep inspiration (specific for cholecystitis)
- Local peritonism (guarding, rebound)
- Palpable gallbladder (Courvoisier's if painless + jaundice = malignancy)
Systemic Signs
- Jaundice (suggests CBD stone)
- Pallor (if acute cholangitis/sepsis)
Investigations
Blood Tests
| Test | Findings |
|---|---|
| FBC | Raised WCC in cholecystitis |
| CRP | Elevated in cholecystitis |
| LFTs | ALT/ALP raised if CBD stone |
| Bilirubin | Raised if obstruction |
| Amylase/lipase | Elevated if pancreatitis |
Imaging
| Modality | Role |
|---|---|
| Ultrasound | First-line; stones, wall thickening (over 3mm), pericholecystic fluid |
| MRCP | If CBD stone suspected |
| CT | If USS equivocal or complications suspected |
| HIDA scan | Functional imaging if USS normal but cholecystitis suspected |
USS Findings in Cholecystitis
- Gallstones
- Wall thickening over 3mm
- Pericholecystic fluid
- Positive sonographic Murphy's sign
Classification & Staging
Tokyo Guidelines (Acute Cholecystitis Severity)
| Grade | Definition | Management |
|---|---|---|
| Grade I (Mild) | No organ dysfunction, mild local inflammation | Early cholecystectomy |
| Grade II (Moderate) | Elevated WCC, palpable mass, symptoms over 72h, marked local inflammation | Early cholecystectomy (may need drainage first) |
| Grade III (Severe) | Organ dysfunction (cardiovascular, renal, neurological, respiratory, hepatic, haematological) | Supportive care + drainage (cholecystostomy); surgery when stable |
Management
Initial Management
- Nil by mouth
- IV fluids
- Analgesia (NSAIDs, opioids)
- Antiemetics
Biliary Colic (Uncomplicated)
- Conservative management
- Discharge with elective cholecystectomy referral
- Dietary advice (low-fat)
Acute Cholecystitis
1. Antibiotics:
| Regimen | Notes |
|---|---|
| Co-amoxiclav | First-line |
| Ceftriaxone + metronidazole | Alternative |
| Piperacillin-tazobactam | Severe/septic |
2. Early Cholecystectomy (Within 7 Days):
- Now standard of care (NICE, RCS guidelines)
- Laparoscopic preferred
- Reduces overall hospital stay and complications
3. Percutaneous Cholecystostomy:
- For high-risk/unfit patients (Grade III)
- Bridge to interval cholecystectomy
Choledocholithiasis (CBD Stone)
- ERCP + stone extraction before or after cholecystectomy
- MRCP to confirm
Gallstone Pancreatitis
- Conservative pancreatitis management
- Early cholecystectomy (within same admission if possible)
Complications
Of Gallstones
- Cholecystitis
- Choledocholithiasis (CBD stone)
- Cholangitis
- Gallstone pancreatitis
- Gallstone ileus (rare)
- Mirizzi syndrome
- Gallbladder carcinoma (chronic stones)
Of Cholecystitis
- Empyema
- Gangrene
- Perforation → peritonitis/abscess
- Sepsis
Of Surgery
- Bile duct injury (0.1-0.5%)
- Bile leak
- Bleeding
- Retained CBD stone
Prognosis & Outcomes
Biliary Colic
- Recurrence common without cholecystectomy
- Low mortality
Cholecystitis
- Excellent outcomes with early surgery
- Mortality under 1% (higher in elderly, severe disease)
Laparoscopic Cholecystectomy
- Day-case or short stay
- Low complication rate
- Conversion to open: 5-10%
Evidence & Guidelines
Key Guidelines
- NICE NG104: Gallstone Disease (2014)
- Tokyo Guidelines (TG18): Acute Cholecystitis (2018)
- RCS/AUGIS: Commissioning Guide for Gallstone Disease
Key Evidence
- Early cholecystectomy (under 7 days) reduces total hospital stay and complications
- ERCP before cholecystectomy for CBD stones reduces complications
Patient & Family Information
What are Gallstones?
Gallstones are small stones that form in the gallbladder. They are common and often cause no symptoms, but can cause pain and inflammation.
Biliary Colic
- Episodes of pain after eating, especially fatty food
- Pain usually settles within a few hours
Cholecystitis
- Inflammation of the gallbladder
- Persistent pain, fever, feeling unwell
- Needs antibiotics and usually surgery
Treatment
- Keyhole surgery to remove the gallbladder (cholecystectomy)
- Most people go home the same day or next day
After Surgery
- You can live normally without a gallbladder
- Some people get loose stools initially (usually settles)
Resources
References
Primary Guidelines
- NICE. Gallstone Disease: Diagnosis and Management (NG104). 2014. nice.org.uk
- Yokoe M, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):41-54. PMID: 29032636
Key Studies
- Gutt CN, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study). Ann Surg. 2013;258(3):385-393. PMID: 24022431