Lecture
41-year-old with acute abdominal pain
Patient will present as → a 42-year-old female presents to the clinic with episodic right upper quadrant (RUQ) pain that started several months ago. She describes the pain as sharp, lasting about 1–2 hours, and occurring after eating fatty meals. The pain sometimes radiates to her right shoulder/scapula or back and is associated with nausea, but she denies fever, chills, or vomiting. Her medical history is significant for obesity and hyperlipidemia. On physical examination, she is afebrile, with a normal vital sign profile. Her abdomen is soft, non-tender, and without guarding during the visit. Laboratory tests, including liver function tests and complete blood count, are normal. An abdominal ultrasound reveals the presence of multiple mobile echogenic foci in the gallbladder with posterior acoustic shadowing. The patient is diagnosed with cholelithiasis, which is the presence of gallstones in the gallbladder. Since her symptoms are consistent with biliary colic but without signs of cholecystitis or complications, her pain is treated with an NSAID and she is referred for elective laparoscopic cholecystectomy, the recommended definitive treatment for symptomatic gallstones that prevents future attacks and complications. While she waits, she is counseled on reducing fat intake to minimize symptom recurrence. She is advised to return promptly if she develops fever, persistent pain, jaundice, or other concerning symptoms, which could indicate cholecystitis or gallstone-related complications. Follow-up is arranged with surgery.
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Cholelithiasis refers to stones in the gallbladder (i.e., gallstones) without inflammation
- Most cases are asymptomatic, and the majority of patients found to have incidental gallstones will remain asymptomatic
- Cholesterol stones account for most (about 75% or more) of gallstones in the Western world - (Fat, female, forty, and fertile) OCPs, chronic hemolysis, cirrhosis, infection, rapid weight loss, IBD, TPN, fibrates, increased triglycerides
- 10% are pigmented - black, brown, and mixed
Biliary colic is the cardinal symptom of gallstones and is due to temporary obstruction of the cystic duct by a gallstone. Pain occurs as the gallbladder contracts against this obstruction
- Classically presents as right upper quadrant pain that begins abruptly, is steady (not truly colicky), and resolves within about 6 hours (usually 30 minutes to a few hours), is associated with nausea and precipitated by fatty foods and large meals
- Boas sign—referred right subscapular pain of biliary colic
Complications of cholelithiasis:
- Cholecystitis: cystic duct obstruction by gallstones
- Choledocholithiasis: gallstones in the biliary tree – associated with ductal dilation and biliary colic or jaundice. Treat with stone extraction via ERCP
- Cholangitis: biliary tract infection secondary to obstruction by gallstones. Treat with antibiotics and ERCP drainage
- Gallstone pancreatitis: a stone obstructing the ampulla; epigastric pain radiating to the back with lipase at least 3 times normal
The diagnostic procedure of choice in this patient is abdominal ultrasonography
- Ultrasound examination should be done after 8 hours of fasting because gallstones are visualized better in a distended, bile-filled gallbladder
Alkaline phosphatase (ALK-P): Not specific to the liver—also found in bone, gut, and placenta
- ALK-P is elevated when there is an obstruction to bile flow (e.g., cholestasis) in any part of the biliary tree. Normal levels make cholestasis unlikely.
Bilirubin
GGT is often used to confirm that the ALK-P elevation is of hepatic origin
Albumin—decreased in chronic liver disease, nephrotic syndrome, malnutrition, and inflammatory states (e.g., burns, sepsis, trauma)
Prothrombin time
- The liver synthesizes most clotting factors; PT reflects factors I (fibrinogen), II, V, VII, and X.
- PT is not prolonged until most of the liver’s synthetic capacity is lost, which corresponds to advanced liver disease.
If asymptomatic: observe (expectant management); prophylactic cholecystectomy is not recommended, even in diabetics (exceptions include a porcelain gallbladder, stones over 3 cm, or a gallbladder polyp 1 cm or larger)
- Lifestyle modifications such as reducing fat intake, maintaining a healthy weight, avoiding rapid weight loss, and controlling underlying conditions such as diabetes
- Symptomatic (biliary colic): elective laparoscopic cholecystectomy (after a single mild, uncomplicated attack, watchful waiting is a reasonable option)
- Biliary colic pain: NSAIDs first-line (for example, ketorolac); opioids if needed
- Ursodeoxycholic acid only for patients who cannot or will not have surgery (small cholesterol stones; slow, and stones often recur)
 Osmosis |
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Question 1 |
Black pigment stones Hint: Form from excess bilirubin in chronic hemolysis (sickle cell disease, hereditary spherocytosis) or cirrhosis. | |
Brown pigment stones Hint: Form in infected bile ducts, often with biliary parasites or strictures. | |
Calcium oxalate stones Hint: A common kidney stone, not a gallstone type. | |
Cholesterol stones | |
Struvite stones Hint: A kidney stone associated with urease-producing urinary infections. |
Question 2 |
Abdominal radiograph Hint: Most gallstones are not radiopaque, so plain films usually miss them. | |
Cholescintigraphy (HIDA scan) Hint: Used for suspected acute cholecystitis when ultrasound is equivocal, not for detecting stones. | |
Endoscopic retrograde cholangiopancreatography Hint: Invasive; reserved for removing common bile duct stones or draining cholangitis. | |
Right upper quadrant ultrasound | |
Upper endoscopy Hint: Looks for ulcers or gastritis and cannot image the gallbladder. |
Question 3 |
Elective laparoscopic cholecystectomy | |
Endoscopic retrograde cholangiopancreatography Hint: Used to clear common bile duct stones; her bile duct and liver tests are normal. | |
Extracorporeal shock wave lithotripsy Hint: Rarely used today; low clearance rates and stones recur. | |
Observation with reassurance Hint: Appropriate for asymptomatic stones, but her stones are causing recurrent symptoms. | |
Ursodeoxycholic acid therapy Hint: Reserved for patients who cannot or will not have surgery; it is slow and stones often recur. |
Question 4 |
Elective laparoscopic cholecystectomy Hint: Prophylactic cholecystectomy is not recommended for asymptomatic stones, and diabetes alone is not an indication. | |
Endoscopic retrograde cholangiopancreatography Hint: Has no role for asymptomatic gallbladder stones. | |
Expectant management | |
Percutaneous cholecystostomy Hint: Drains an acutely inflamed gallbladder in critically ill patients; he has no inflammation. | |
Ursodeoxycholic acid therapy Hint: Not used for asymptomatic stones. |
Question 5 |
Hyoscyamine Hint: Antispasmodics are not effective for biliary pain, which is steady rather than truly colicky. | |
Ketorolac | |
Meperidine Hint: An outdated choice with neurotoxic metabolites; no advantage over other agents. | |
Morphine Hint: Acceptable if pain is not controlled, but NSAIDs are first-line. | |
Oxycodone Hint: An opioid option for refractory pain, but NSAIDs are preferred first. |
Question 6 |
Black pigment stones | |
Brown pigment stones Hint: Form in infected bile ducts, often with parasites or strictures. | |
Calcium oxalate stones Hint: A kidney stone, not a gallstone. | |
Cholesterol stones Hint: The most common gallstone overall, but chronic hemolysis causes pigment stones. | |
Cystine stones Hint: A kidney stone from an inherited amino acid transport defect. |
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References: Merck Manual · UpToDate