Biliary Disease


Cholelithiasis (Gallstone) Risk

  • Female
  • Fat (Obesity), also recent weight loss
  • Fertile (Estrogen), Pregnancy
  • Forty (Elderly)
  • Fair (Caucasians/Northern European but also Hispanic)
  • Family history
  • Liver transplant


  • Abdominal Exam
    • Murphy's sign
  • Labs
    • Leukocytosis (left shift)
    • Bilirubin
    • Alk Phos
    • ALT
    • Amylase
      • Abnormal LFTs are not common in uncomplicated acute cholecystitis, as obstruction limited to gallbladder
  • Ultrasonography
    • Sonographic Murphy's sign
    • Gallbladder wall thickening >4mm or edema (double wall sign)
    • Pericholecystic fluid
  • CT vs. MRCP if ultrasound unclear or if complications suspected



  • Surgery referral for symptomatic gallstones (biliary colic)
    • Analgesia (NSAIDs, narcotic as second-line)
  • Expectant management for asymptomatic gallstones (only 10-20% will become symptomatic within 5-20y)
    • Surgery may be considered in asymptomatic gallstones in the following situations:
      • Calcification of the gallbladder (porcelain gallbladder) because of high risk for gallbladder cancer
      • Hemolytic anemia (e.g., sickle cell disease)
      • Large gallstones (greater than 3 cm) because of high risk for gallbladder cancer
      • Morbidly obese undergoing bariatric surgery because of high risk to becoming symptomatic during rapid weight loss
      • Aboriginals because of high risk for gallbladder cancer
      • Planning for a transplant


  • Distinguish from biliary colic
    • Lack of pain resolution, fever, peritonitis, abnormal labs
  • Types
    • Calculous cholecystitis
    • Acalculous cholecystitis - 10% (usually in critically ill patients)
  • Treatment
    • No need for antibiotic prophylaxis in low risk
    • Cholecystectomy
    • Untreated, resolves within 7-10d but risk of complications (20% gallbladder gangrene, 2% perforation)

Choledocolithiasis / Cholangitis

  • Gallstone in common bile duct
  • Risk of pancreatitis and acute cholangitis
    • Charcot's Triad
      • RUQ pain
      • Jaundice
      • Fever
    • Raynaud's Pentad (above PLUS)
      • Confusion
      • Shock
  • Treatment
    • Antibiotics
    • ERCP with stone removal/cholecystectomy