One-page cheat sheet
Gallstones and cholecystitis
From biliary colic to cholangitis
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The spectrum
- Biliary colic: RUQ or epigastric pain under 6 hours, often after fatty food, no fever
- Acute cholecystitis: pain over 6 hours, fever, Murphy’s sign, raised WCC
- CBD stones: jaundice, dark urine, raised ALP/bilirubin
- Cholangitis: Charcot’s triad (fever, jaundice, RUQ pain); Reynolds’ pentad adds shock and confusion
- Also: gallstone pancreatitis, gallstone ileus (Rigler’s triad), Mirizzi syndrome
Risk factors
- Female, forty, fertile, fat
- Rapid weight loss (including after bariatric surgery), pregnancy
- Haemolysis (pigment stones), terminal ileal disease or resection
Investigations
- Ultrasound first: stones, wall over 3 mm, pericholecystic fluid, sonographic Murphy’s
- LFTs, lipase, FBC, CRP; blood cultures if febrile
- MRCP if CBD stones are suspected (dilated duct, abnormal LFTs); EUS is an alternative
- ERCP is for treatment, not diagnosis
- Grade severity with the Tokyo Guidelines 2018
Management
- Biliary colic: elective laparoscopic cholecystectomy
- Acute cholecystitis: antibiotics and early cholecystectomy within a week of diagnosis (NICE)
- Unfit for surgery: percutaneous cholecystostomy
- CBD stones: ERCP and sphincterotomy, then cholecystectomy (or laparoscopic CBD exploration)
- Cholangitis: resuscitate, IV antibiotics, urgent biliary drainage (ERCP); emergency if septic shock
- Mild gallstone pancreatitis: cholecystectomy on the same admission
Safe cholecystectomy
- Critical view of safety: hepatocystic triangle cleared; lower third of the gallbladder off the liver bed; only two structures entering the gallbladder
- If the anatomy is unclear: stop, call for help, or do a subtotal cholecystectomy
- Bile duct injury: about 0.3–0.5%
Exam pearls
- Murphy’s sign can be absent in the elderly
- Acalculous cholecystitis: critically ill ICU patients
- Courvoisier: a palpable non-tender gallbladder with jaundice is rarely due to stones