Gallstones (Cholelithiasis)
Biliary colic, cholecystitis, cholangitis and surgical management per NICE CG188
Gallstones are calculi within the gallbladder or biliary tract, present in around 10–15% of the UK adult population. Most are asymptomatic. Symptomatic disease ranges from biliary colic to life-threatening acute cholangitis. Laparoscopic cholecystectomy is the definitive treatment for symptomatic gallstones and should be offered promptly per NICE CG188.
Complications of Gallstones
Biliary colic occurs when a stone temporarily obstructs the cystic duct — it presents as severe right upper quadrant or epigastric pain lasting 30 minutes to 6 hours, radiating to the right shoulder, often triggered by fatty meals. Acute cholecystitis is sustained cystic duct obstruction with secondary bacterial infection — presenting with persistent RUQ pain, fever, and a positive Murphy's sign. Choledocholithiasis (CBD stone) causes obstructive jaundice, pale stools, and dark urine. Acute cholangitis (Charcot's triad: RUQ pain, fever, jaundice) is a septic emergency. Acute pancreatitis may be precipitated by passage of a gallstone through the ampulla of Vater.
Investigation and Treatment
Ultrasound abdomen is the first-line investigation and has over 95% sensitivity for gallstones. LFTs and amylase should be checked to assess for cholestasis or pancreatitis. MRCP is the gold-standard non-invasive investigation for CBD stones. Analgesia for biliary colic: diclofenac 75 mg IM or 100 mg PR is first-line (NSAIDs superior to opioids for biliary spasm). For acute cholecystitis, co-amoxiclav 625 mg three times daily (community) or IV piperacillin-tazobactam (hospital) is recommended. Definitive treatment is laparoscopic cholecystectomy — NICE CG188 recommends offering this within 1 week of acute presentation where surgically feasible.
ERCP and Medical Dissolution
ERCP with sphincterotomy is both diagnostic and therapeutic for CBD stones — performed before or after cholecystectomy. Emergency ERCP is required within 24 hours for cholangitis with CBD obstruction. Ursodeoxycholic acid (8–15 mg/kg/day) can dissolve small radiolucent cholesterol stones in patients unfit for surgery, but takes 6–24 months and has a recurrence rate of approximately 50% after stopping. UDCA is also used long-term for primary biliary cholangitis at a dose of 13–15 mg/kg/day.