The NCCPA™ PANCE Gastroenterology and Nutrition Content Blueprint (current edition) lists the following topics under biliary disorders:
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Cholelithiasis vs. Cholecystitis vs. Choledocholithiasis vs. Cholangitis
| Cholelithiasis | Acute Cholecystitis | Choledocholithiasis | Cholangitis |
| The presence of gallstones in the gallbladder
A precursor to cholecystitis |
Inflammation of the gallbladder usually due to gallstones | Presence of gallstones in the common bile duct | Infection/inflammation of the bile ducts |
| Formation of gallstones due to cholesterol or bilirubin | Blockage of cystic duct by gallstones | Migration of gallstones from the gallbladder to the common bile duct | Blockage of bile ducts, often due to gallstones, leading to bacterial infection |
| Often asymptomatic; biliary colic | Severe RUQ pain, low-grade fever, nausea, vomiting, positive Murphy’s sign | RUQ pain, jaundice, dark urine, pale stools | Charcot's triad: RUQ pain, fever, jaundice
Reynolds pentad: add hypotension and altered mental status |
| Ultrasound | Ultrasound, HIDA scan (gold standard) | Ultrasound first, then MRCP or endoscopic ultrasound; ERCP to remove stones | ERCP, MRCP, blood cultures |
| Asymptomatic: observation; symptomatic: cholecystectomy | Antibiotics, early laparoscopic cholecystectomy | ERCP to remove stones, followed by cholecystectomy | Antibiotics, ERCP to drain the bile duct |
| Biliary colic, acute cholecystitis | Gallbladder gangrene, perforation | Pancreatitis, cholangitis | Sepsis, liver abscess, recurrent cholangitis |
| Acute and chronic cholecystitis | Patient will present as → a 40-year-old female presents with a 24-hour history of constant, severe right upper quadrant abdominal pain. She describes the pain as sharp and radiating to her back, worsening after meals. She also reports a low-grade fever and nausea. Her past medical history includes multiple episodes of similar but less severe pain. On examination, she has a fever of 38.2°C (100.8°F), and her right upper quadrant is notably tender with a positive Murphy’s sign. Laboratory tests show elevated white blood cell count and mild elevation in liver enzymes. An abdominal ultrasound reveals a thickened gallbladder wall and gallstones, consistent with acute cholecystitis. She is admitted for intravenous antibiotics and surgical consultation for cholecystectomy. Acute cholecystitis is persistent cystic duct obstruction by a gallstone causing gallbladder wall inflammation, presenting with RUQ pain lasting >6 hours, fever, and a positive Murphy's sign (inspiratory arrest with RUQ palpation).
DX: RUQ ultrasound: first-line — gallstones, wall thickening (>4 mm), pericholecystic fluid, sonographic Murphy's sign
TX: Laparoscopic cholecystectomy — definitive treatment; perform early, during the same admission (ideally within 72 hours)
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| Cholangitis | Patient will present as → a 58-year-old male with acute onset of abdominal pain associated with fever and shaking chills. The patient is hypotensive and febrile with a temperature of 102.2 ° F. Although he is confused and disoriented, he complains of right upper quadrant pain during palpation of the abdomen. His sclerae are icteric, and the skin is jaundiced Ascending cholangitis is a life-threatening infection of the biliary tree caused by biliary obstruction (most commonly choledocholithiasis) that allows gut bacteria to ascend, producing Charcot's triad (RUQ pain + fever/chills + jaundice) and, in severe cases, Reynolds' pentad (adds hypotension + altered mental status). Urgent ERCP with biliary decompression is the definitive treatment.
DX: Clinical diagnosis (Charcot/Reynolds) + imaging evidence of obstruction
TX: Immediate management: IV fluids, NPO, analgesia, obtain blood cultures
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| Cholelithiasis | ReelDx Virtual Rounds (acute cholelithiasis)Patient will present as → a 43-year-old woman who comes to the emergency department with a 3-hour history of steady right upper quadrant (RUQ) abdominal pain that began an hour after a fatty meal. The pain is associated with nausea and some episodes of vomiting. The pain sometimes radiates through to the back. She has had two similar, shorter episodes after meals in the past month. There is no diarrhea. Her last bowel movement was 1 day ago and was normal. On examination, the patient is an obese young woman in some discomfort. Her vital signs reveal a temperature of 98.6°F (37°C) and pulse of 92 beats/minute. Her blood pressure is 130/70 mmHg, and her respirations are 18 breaths/minute. There is no scleral icterus. The chest is clear, and the cardiovascular examination is normal. Abdominal examination reveals mild RUQ tenderness without guarding, and Murphy’s sign is negative. Bowel sounds are normal. White blood cell count, liver tests, and lipase are normal, and ultrasound shows gallstones without gallbladder wall thickening or pericholecystic fluid. The patient has no drug allergies and is not taking any medications at present. Cholelithiasis (stones in the gallbladder) is the formation of gallstones (usually cholesterol stones, about 75% or more in Western countries) due to bile supersaturation and stasis.
DX: RUQ ultrasound (first-line and best initial test) showing echogenic stones with posterior acoustic shadowing; no wall thickening or pericholecystic fluid
TX: No intervention if asymptomatic (no prophylactic cholecystectomy, even in diabetics; exceptions include a porcelain gallbladder, stones over 3 cm, or a polyp 1 cm or larger)
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