Gallstones, Cholecystitis and Cholangitis Compared

Gallstones (cholelithiasis) are very common, and most never cause symptoms. When they do, they produce a spectrum of problems: biliary colic, acute cholecystitis, common bile duct stones with jaundice, cholangitis and gallstone pancreatitis. Knowing how to tell these apart is a core surgical skill.

Risk factors

The classic "4 Fs":

• Female.
• Forty or older.
• Fat (obesity).
• Fertile (multiparity, pregnancy).

Other risk factors:

• family history
• rapid weight loss, including after bariatric surgery
• diabetes
• oestrogens
• haemolytic diseases such as thalassaemia and sickle cell disease (pigment stones)
• terminal ileal disease

The spectrum of gallstone disease

Biliary colic

• Mechanism: a stone temporarily blocks the gallbladder neck.
• Pain: right upper quadrant or epigastric, often after fatty meals; lasts minutes to hours, then resolves.
• Fever and jaundice: no.

Acute cholecystitis

• Mechanism: persistent obstruction with inflammation of the gallbladder wall.
• Pain: constant right upper quadrant pain lasting more than 6 hours.
• Fever: yes. Jaundice: usually no.
• Key sign: Murphy's sign is positive.

Choledocholithiasis

• Mechanism: a stone in the common bile duct.
• Pain: may be painful or painless.
• Fever: no. Jaundice: yes, obstructive (dark urine, pale stools).

Ascending cholangitis

• Mechanism: infection of an obstructed bile duct.
• Pain: right upper quadrant pain, often with rigors.
• Fever and jaundice: yes.
• Classic signs: Charcot's triad of fever, jaundice and right upper quadrant pain.

Reynolds' pentad is Charcot's triad plus confusion and hypotension. It indicates severe cholangitis with sepsis.

Investigations

• Blood tests:
  • full blood count
  • CRP
  • liver function tests (raised bilirubin and ALP with duct obstruction)
  • amylase or lipase (to exclude pancreatitis)
  • blood cultures if febrile
• Abdominal ultrasound is the first-line imaging test. It shows:
  • stones
  • gallbladder wall thickening
  • pericholecystic fluid
  • a dilated common bile duct
• MRCP (magnetic resonance cholangiopancreatography) or endoscopic ultrasound to detect duct stones.
• ERCP is therapeutic rather than diagnostic: it removes duct stones.

Management

• Asymptomatic gallstones: usually no treatment.
• Biliary colic: analgesia, then elective laparoscopic cholecystectomy.
• Acute cholecystitis:
  • IV fluids, analgesia and antibiotics
  • early laparoscopic cholecystectomy, ideally within 1 week of diagnosis (NICE), when the patient is fit
  • percutaneous cholecystostomy for very unwell or high-risk patients
• Common bile duct stones: ERCP with stone extraction, or surgical duct exploration, plus cholecystectomy.
• Cholangitis: resuscitation, IV antibiotics and urgent biliary drainage (ERCP), with timing according to severity.

Complications

• Empyema of the gallbladder.
• Gangrene and perforation.
• Mirizzi syndrome.
• Gallstone ileus (a stone obstructing the small bowel through a fistula).
• Pancreatitis.
• Gallbladder cancer (rare).

Exam pearls

• Charcot's triad means cholangitis, and it needs urgent drainage.
• Painless jaundice with a palpable gallbladder (Courvoisier's law) suggests malignancy, not gallstones.
• Gallstone ileus: small bowel obstruction plus air in the biliary tree (pneumobilia).

See also Acute Pancreatitis and our Surgery Companion (hepatobiliary chapter).

Test yourself

5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.

1. Fever, jaundice and right upper quadrant pain together are called:

   1. Virchow's triad
   2. Charcot's triad
   3. Cushing's triad
   4. Beck's triad
   5. Reynolds' pentad
   Show answer

   Answer: B. Charcot's triad
   Charcot's triad indicates ascending cholangitis.

2. First-line imaging for suspected gallstone disease:

   1. Plain X-ray
   2. MRI brain
   3. ERCP
   4. CT
   5. Abdominal ultrasound
   Show answer

   Answer: E. Abdominal ultrasound
   Ultrasound detects stones, wall thickening and duct dilatation.

3. Positive Murphy's sign suggests:

   1. Pancreatitis
   2. Appendicitis
   3. Acute cholecystitis
   4. Peptic ulcer
   5. Renal colic
   Show answer

   Answer: C. Acute cholecystitis
   Inspiratory arrest on palpation of the right upper quadrant suggests an inflamed gallbladder.

4. Painless jaundice with a palpable gallbladder suggests:

   1. Hepatitis A
   2. Malignancy such as pancreatic head cancer
   3. Gallstones
   4. Cholecystitis
   5. Biliary colic
   Show answer

   Answer: B. Malignancy such as pancreatic head cancer
   Courvoisier's law: a palpable gallbladder with painless jaundice is unlikely to be due to stones.

5. Ascending cholangitis requires:

   1. Ursodeoxycholic acid only
   2. Diet only
   3. Elective surgery in 6 months
   4. Resuscitation, IV antibiotics and urgent biliary drainage (ERCP)
   5. Oral antibiotics at home
   Show answer

   Answer: D. Resuscitation, IV antibiotics and urgent biliary drainage (ERCP)
   Biliary drainage is essential in cholangitis.

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Disclaimer

For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.