Gallstone disease: colic, cholecystitis, cholangitis
Fever plus deranged LFTs in a patient with gallstones is cholangitis until proven otherwise. Treat it early and get the duct drained.
A 45-year-old woman has had constant right upper quadrant pain for 18 hours with fever 38.4 °C. Murphy's sign is positive. Bilirubin normal.
A 68-year-old man has jaundice, rigors and right upper quadrant pain. Temperature 39.2 °C, BP 94/58, bilirubin 4.8 mg/dL (82 µmol/L).
A 38-year-old woman had 2 hours of colicky right upper quadrant pain after a fatty meal, now settled. Bloods normal.
Which one is biliary colic, which is cholecystitis, and which is the emergency?
- BloodsFBC, CRP, LFT, amylase or lipase, U&E, clotting, cultures if feverish.
- UltrasoundGallstones, wall thickening, fluid, duct dilatation.
- Biliary colicAnalgesia, home, elective laparoscopic cholecystectomy.
- Acute cholecystitisAdmit, IV antibiotics, analgesia. Early cholecystectomy (within 1 week, ideally 72 hours).
- CholangitisFever, jaundice, pain (Charcot's triad). Sepsis bundle, antibiotics, ERCP within 24–48 hours (urgent if shocked).
- Gallstone pancreatitisTreat pancreatitis. ERCP if cholangitis or persistent obstruction.
- Common bile duct stonesMRCP or EUS if suspected, ERCP to clear.
- Cholangitis with shock or confusion
- Jaundice with fever
- Gallstone pancreatitis
- Gangrenous or perforated gallbladder
- Elderly or diabetic with cholecystitis
- Cholangitis
- Pancreatitis
- Gallbladder perforation or empyema
- Acalculous cholecystitis in ICU patients
- Inferior MI
- Peptic ulcer
- Right lower lobe pneumonia
- Liver abscess
| Biliary colic | Pain under about 6 hours, no fever, normal bloods |
| Acute cholecystitis | Constant pain over 6 hours, fever, Murphy's sign, raised WBC |
| Charcot's triad | Fever, jaundice, right upper quadrant pain |
| Reynolds' pentad | Charcot's plus confusion and shock |
| CBD dilated | Over about 6 mm (more in the elderly and after cholecystectomy) |
| Early cholecystectomy | Within 1 week of symptoms, ideally 72 hours |
Check every dose against a current drug reference and your hospital protocol.
On this page
Spectrum of gallstone disease
| Condition | Pain | Fever | Jaundice | Bloods |
|---|---|---|---|---|
| Biliary colic | Colicky, under 6 hours | No | No | Normal |
| Acute cholecystitis | Constant, over 6 hours, Murphy's sign | Yes | Mild or no | High WBC, CRP |
| Choledocholithiasis | Colicky | No | Yes | Obstructive LFTs |
| Cholangitis | Constant | High, rigors | Yes | High WBC, obstructive LFTs, often shocked |
| Gallstone pancreatitis | Epigastric to back | Possible | Possible | Lipase or amylase 3 times normal |
Which one is it?
Biliary colic: home, elective surgery
Acute cholecystitis: admit, antibiotics, early surgery
Cholangitis: sepsis treatment, urgent ERCP
Pancreatitis
Investigations
| Test | Why |
|---|---|
| Ultrasound | Stones, wall thickening, pericholecystic fluid, duct dilatation |
| LFT | Obstructive pattern (bilirubin, ALP, GGT) |
| Lipase or amylase | Pancreatitis |
| FBC, CRP | Infection |
| Blood cultures | Fever |
| MRCP | Suspected duct stones |
| CT | Complications (perforation, pancreatitis, abscess) or unclear diagnosis |
| ECG | Inferior MI mimic |
Management
- AdmitAnalgesia, IV fluids, antiemetic.
- AntibioticsIV, per local guidance.
- Early cholecystectomyWithin 1 week, ideally 72 hours, in fit patients.
- Not fit for surgery or not improvingPercutaneous cholecystostomy.
- Sepsis bundleCultures, antibiotics within 1 hour, fluids, lactate.
- Biliary drainageERCP: urgent (within 24 hours or sooner) if shocked, within 48–72 hours if responding.
- Then cholecystectomyOnce recovered.
Treatment
See pancreatitis and sepsis.
Special situations
- Pregnancy: ultrasound; surgery is safest in the second trimester.
- Elderly and diabetics: higher risk of gangrene and perforation, fewer signs.
- ICU patients: acalculous cholecystitis without stones.
- Mirizzi syndrome: a stone in the gallbladder neck compresses the common hepatic duct, causing jaundice.
Common mistakes
- Missing cholangitis in a jaundiced, feverish patient.
- Discharging cholecystitis as colic.
- Delaying ERCP in shocked cholangitis.
- Forgetting the ECG.
- Delaying surgery for weeks "to let it cool down" in fit patients.
- Missing duct stones in a patient with abnormal LFTs.
Frequently asked questions
What is the difference between biliary colic and cholecystitis?
Biliary colic is short pain without fever and with normal bloods. Cholecystitis is constant pain over 6 hours with fever, Murphy's sign and raised inflammatory markers.
What is Charcot's triad?
Fever, jaundice and right upper quadrant pain, the classic features of cholangitis.
When should cholecystectomy be done after acute cholecystitis?
Early, within 1 week of symptoms and ideally within 72 hours, in fit patients.
What is the treatment for cholangitis?
Antibiotics, fluids and biliary drainage by ERCP, urgently if the patient is shocked.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A woman with gallstones has fever, rigors, jaundice and right upper quadrant pain. What is the diagnosis?
Answer: Ascending cholangitis. Charcot's triad indicates cholangitis: antibiotics and biliary drainage by ERCP.
- Hepatitis A: Not with gallstones and rigors.
- Pancreatitis: Possible but not the main picture.
- Biliary colic: No fever or jaundice.
- Acute cholecystitis: Jaundice suggests a duct problem.
2. A 45-year-old has acute cholecystitis confirmed on ultrasound. When should cholecystectomy ideally be done?
Answer: Same admission, within 72 hours. Early laparoscopic cholecystectomy is recommended for fit patients.
- Only if a stone is in the duct: Not the criterion.
- After 6 weeks routinely: Early surgery reduces complications and readmission.
- After 6 months: Too late.
- Never: Recurrence is common.
3. Why should every gallbladder removed in Pakistan be sent for histology?
Answer: Gallbladder cancer is common. Gallbladder cancer is common in parts of Pakistan and can be found incidentally.
- For legal reasons only: Not the reason.
- To test for typhoid: Not routine.
- To count the stones: Not the reason.
- Because of hydatid cysts: Not the reason.
4. A 70-year-old has fever with rigors, jaundice and RUQ pain. BP is 85/50 and he is confused. Ultrasound shows a dilated common bile duct with stones. After resuscitation and antibiotics, what is needed urgently?
Answer: ERCP and biliary drainage. Acute cholangitis: Charcot triad (fever, jaundice, RUQ pain); Reynolds pentad adds hypotension and confusion (severe). Causes: CBD stones, strictures, malignancy, blocked stents. Management: resuscitation, blood cultures, IV antibiotics, and urgent biliary decompression — ERCP with sphincterotomy and stone extraction/stent (within 24 h in severe disease); PTC if ERCP fails. Cholecystectomy later.
- Laparoscopic cholecystectomy now: Cholecystectomy does not drain the infected duct.
- Oral antibiotics at home: He has severe sepsis.
- MRCP in 2 weeks: Two weeks is far too long.
5. Three days after laparoscopic cholecystectomy, a patient has abdominal pain, fever and mild jaundice. Ultrasound shows a subhepatic collection. What is the likely cause and treatment?
Answer: Bile leak — drain + ERCP. Bile leak after cholecystectomy (cystic duct stump, ducts of Luschka, or bile duct injury) presents with pain, fever, bilious drain fluid or a subhepatic collection/biloma. Investigate with ultrasound/CT; HIDA or MRCP. Treat with percutaneous drainage plus ERCP with sphincterotomy/stent (reduces transpapillary pressure). Major bile duct injury needs hepaticojejunostomy in a specialist centre.
- Retained stone only — reassure: A collection is present, so this is not just a retained stone.
- Pancreatitis — conservative: This picture does not fit pancreatitis.
- Normal post-op recovery: Fever with a collection is abnormal.
6. During laparoscopic cholecystectomy, the surgeon dissects Calot's triangle to find which structure?
Answer: Cystic artery. Calot's triangle (hepatocystic triangle) is bounded by the cystic duct, common hepatic duct and the inferior surface of the liver. The cystic artery (usually from the right hepatic artery) runs through it, along with Calot's lymph node. Clearly identifying the cystic duct and artery here prevents bile duct injury.
- Common bile duct only: A boundary, not the content.
- Portal vein: Behind the common bile duct, outside the triangle.
- Gastroduodenal artery: Below the first part of the duodenum.
- Right gastric artery: Runs along the lesser curvature.
7. A healthy young man becomes mildly jaundiced when fasting during Ramadan or when unwell. Unconjugated bilirubin is slightly raised; liver enzymes and blood count are normal. What is the diagnosis?
Answer: Gilbert syndrome. Gilbert syndrome is common and benign: reduced UGT1A1 activity causes mild unconjugated hyperbilirubinaemia, especially with fasting, illness or stress. No treatment is needed. Crigler–Najjar type I (absent UGT) causes severe neonatal jaundice and kernicterus. Dubin–Johnson causes conjugated hyperbilirubinaemia with a black liver.
- Crigler–Najjar syndrome type I: Severe from birth; kernicterus.
- Dubin–Johnson syndrome: Conjugated, not unconjugated.
- Haemolytic anaemia: Blood count would be abnormal (anaemia, reticulocytes).
- Acute viral hepatitis: Liver enzymes would be raised.
References and dose sources
- Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis
- Tokyo Guidelines 2018: acute cholecystitis
- NICE CG188 — gallstone disease
- Tokyo Guidelines 2018 — acute cholangitis and cholecystitis
- Diclofenac dosing: Drugs.com: Diclofenac dosage (see also our diclofenac dose page)
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
- Morphine dosing: Drugs.com: Morphine dosage (see also our morphine dose page)
- Ceftriaxone dosing: Drugs.com: Ceftriaxone dosage (see also our ceftriaxone dose page)
- Piperacillin-tazobactam dosing: Drugs.com: Piperacillin/tazobactam dosage (see also our piperacillin-tazobactam dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.