Signs and Symptoms
Asymptomatic
- See management section
- Typically found incidentally on imaging
- Become problematic in about:
- 1-4% of patients within a year
- 10% of patients within 10 years
- 20% of patients within 20 years
- Most patients will experience symptoms of biliary colic before developing complications
- The longer the gallstones remain quiescent, the less likely the patient is to develop complications
Symptomatic
- Biliary colic
- caused by the gallbladder contracting against an obstructed cystic duct
- patients present with pain that is:
- severe - can last from 15 minutes to 24 hours and may wake patient at night
- intermittent - typically separated by weeks/months
- located in the right upper quadrant or epigastric region - may radiate to the right scapula, shoulder or, occasionally, retrosternally
- gradually resolving:
- resolves when the gallbladder stops contracting, or the cystic duct becomes patent again
- either spontaneously or with analgesics
- pain that does not resolve could be indicative of a complication
- typically brought on by fatty foods
- sometimes associated with diaphoresis, nausea, and/or vomiting
- atypically associated with belching, bloating, flatulence, and/or dyspepsia
- Acute cholecystitis or empyema
- Acute pancreatitis
- Common bile duct stones (CBDS)
- Acute cholangitis
- Obstructive jaundice
- Mucocoele of gallbladder
- Gallstone ileus - rare
Severe complications affect only 1-3% of symptomatic gallstone patients
History and Examination
History
For symptomatic patients take a thorough history to include details of:
- Symptoms:
- pain:
- onset
- severity
- site
- nature (biliary colic rarely has features of a colic)
- aggravating and relieving factors
- jaundice
- fever, chills, or rigors
- change in bowel habit
- weight loss
- Previous episodes of biliary colic
- Past history of gallstone disease
- Family history of gallstone disease
- Current medications
Examination
Perform a thorough examination to check for signs of associated complications, such as:
- Signs of:
- inflammation, e.g. fever
- an acute abdomen
- A positive Murphy's sign - indicative of inflammation associated with acute cholecystitis
Uncomplicated biliary colic should reveal normal vital signs and physical examination. Also check for:
- Charcot's cholangitis triad (or Charcot's triad 2):
- pain, jaundice, and fever (usually with rigors)
- indicative of acute cholangitis
- Courvoisier's 'law':
- painless jaundice and a palpable gallbladder
- suggests obstruction from pathology other than gallstones, e.g. pancreatic malignancy
An initial clinical assessment will identify:
- Patients with known gallstone disease who:
- require urgent surgical assessment for serious complications
- present with increasingly frequent and painful episodes of biliary colic, for whom conservative therapy has failed and definitive surgical intervention should be considered
- Patients with asymptomatic gallstones who present with atypical symptoms and signs:
- symptoms should not automatically be attributed to cholelithiasis
- may require further investigation to exclude other causes of epigastric/right upper quadrant pain, including:
- gastritis/peptic ulcer disease
- myocardial ischaemia/infarction (MI)
- pancreatitis
- hepatitis
- inflammatory or neoplastic disease of the colon
- liver/subphrenic abscess
- oesophageal spasm
- irritable bowel syndrome
- Patients who have developed atypical pain and/or non-specific symptoms (e.g. chronic indigestion, vague abdominal pain, bloating, belching) - may merit further investigation
Differential Diagnoses
- Alternative causes of epigastric/right upper quadrant (RUQ) pain include:
- gastritis/peptic ulcer disease
- myocardial ischaemia/infarction (MI)
- pancreatitis
- hepatitis
- inflammatory or neoplastic disease of the colon
- liver/subphrenic abscess
- oesophageal spasm
- irritable bowel syndrome
Joint Formulary – Chapter 1 - Gastrointestinal