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Cholelithiasis Last updated: August 2, 2021

Summary

Cholelithiasis refers to the presence of abnormal concretions (gallstones) in the gallbladder. About 10–20% of American adults have gallstones.
Gallstones most commonly consist of cholesterol but may be pigmented (due to hemolysis or infection) or mixed. Cholelithiasis can manifest with
biliary colic (postprandial RUQ pain) but is most commonly an incidental finding in asymptomatic individuals. The diagnosis is confirmed by
ultrasound. Symptomatic cholelithiasis is managed with laparoscopic cholecystectomy.
See also “Choledocholithiasis”, “Acute cholecystitis”, and “Acute cholangitis.”

Overview

Disorders caused by gallstones

Cholelithiasis Choledocholithiasis Acute cholecystitis Acute cholangitis

Description Presence of gallstones in the gallbladder Presence of Acute inflammation of the Bacterial infection of the biliary tract
gallstones in the gallbladder
common bile duct

Mechanism Bile cholesterol oversaturation, bile Cholelithiasis Cholelithiasis (most common) Choledocholithiasis (most common)
stasis, impaired bile acid circulation migration of or biliary sludge obstruction and stasis within the biliary
precipitation of gallstones in the gallstones into the inflammation of gallbladder tract subsequent bacterial infection
gallbladder common bile duct wall

Clinical Usually asymptomatic RUQ pain > 6 h RUQ pain Charcot triad: RUQ pain, fever,
jaundice
features Symptomatic (biliary colic): RUQ pain < Possible jaundice Fever
6h Reynold pentad:
Murphy sign
Charcot cholangitis triad PLUS
hypotension and mental status changes

Laboratory Normal Total bilirubin WBC, CRP WBC and CRP

findings GGT ALP

ALP AST, ALT
AST, ALT Total bilirubin

Diagnostic US: gallstones with US: dilated US: gallbladder wall US: biliary dilation, and/or evidence of
posterior acoustic shadow common bile duct, thickening and/or edema obstruction (e.g., cholelithiasis),
imaging
intrahepatic biliary (double wall sign) pericholecystic inflammation
dilatation HIDA scan: nonvisualization MRCP if diagnosis uncertain
MRCP or ERCP: of gallbladder > 4 hours after
filling defect in the radioactive tracer
contrast-enhanced administration
duct

Treatment Supportive care, analgesics Supportive care, Supportive care, analgesics Supportive care, analgesics
analgesics
Elective cholecystectomy for: IV antibiotics IV antibiotics
Symptomatic cholelithiasis Endoscopic stone
Cholecystectomy (timing Urgent biliary decompression
retrieval
Asymptomatic cholelithiasis only if at depends on severity) Interval cholecystectomy if gallstones
increased risk of gallbladder cancer Elective See “Acute management are present or concurrent cholecystitis
cholecystectomy to
See “Acute management checklist for checklist for acute
prevent recurrence See “Acute management checklist for
biliary colic.” cholecystitis.” acute cholangitis.”
See “Acute
management
checklist for
choledocholithiasis.”

Epidemiology

Etiology

Clinical features

Diagnostics

Differential diagnoses

Treatment

Acute management checklist

Cholecystectomy

Complications

References

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