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Cholelithiasis

Also known as: Cholecystolithiasis

DiseaseUpdated: 2026-02-05

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 gallstones in the common bile duct
  • Acute inflammation of the gallbladder
  • Bacterial infection of the biliary tract
Mechanism
  • Bile cholesterol oversaturation, bile stasis, impaired bile acid circulation → precipitation of gallstones in the gallbladder
  • Cholelithiasis → migration of gallstones into the common bile duct
  • Cholelithiasis (most common) or biliary sludge → inflammation of gallbladder wall
  • Choledocholithiasis (most common) → obstruction and stasis within the biliary tract → subsequent bacterial infection
Clinical features
  • Usually asymptomatic
  • Symptomatic (biliary colic): RUQ pain < 6 h
  • RUQ pain > 6 h
  • Possible jaundice
  • RUQ pain
  • Fever
  • Murphy sign
  • Charcot triad: RUQ pain, fever, jaundice
  • Reynold pentad: Charcot cholangitis triad PLUS hypotension and mental status changes
Laboratory findings
  • Normal
  • ↑ Total bilirubin
  • ↑ GGT
  • ↑ ALP
  • ↑ AST, ALT
  • ↑ WBC, CRP
  • ↑ WBC and CRP
  • ↑ ALP
  • ↑ AST, ALT
  • ↑ Total bilirubin
Diagnostic imaging
  • US: gallstones with posterior acoustic shadow
  • US: dilated common bile duct, intrahepatic biliary dilatation
  • MRCP or ERCP: filling defect in the contrast-enhanced duct
  • US: gallbladder wall thickening and/or edema (double wall sign)
  • HIDA scan: nonvisualization of gallbladder > 4 hours after radioactive tracer administration
  • US: biliary dilation, and/or evidence of obstruction (e.g., cholelithiasis), pericholecystic inflammation
  • MRCP if diagnosis uncertain
Treatment
  • Supportive care, analgesics
  • Elective cholecystectomy for:
    • Symptomatic cholelithiasis
    • Asymptomatic cholelithiasis only if at increased risk of gallbladder cancer
  • See “Acute management checklist for biliary colic.”
  • Supportive care, analgesics
  • Endoscopic stone retrieval
  • Elective cholecystectomy to prevent recurrence
  • See “Acute management checklist for choledocholithiasis.”
  • Supportive care, analgesics
  • IV antibiotics
  • Cholecystectomy (timing depends on severity)
  • See “Acute management checklist for acute cholecystitis.”
  • Supportive care, analgesics
  • IV antibiotics
  • Urgent biliary decompression
  • Interval cholecystectomy if gallstones are present or concurrent cholecystitis
  • See “Acute management checklist for acute cholangitis.”
Extrahepatic biliary tree
Extrahepatic biliary tree

The right and left hepatic ducts join to form the common hepatic duct. The cystic duct joins the common hepatic duct to form the common bile duct. The main pancreatic duct drains into the common bile duct. The common bile duct opens into the descending part of the duodenum.


© AMBOSS
Cholelithiasis, cholangitis, and biliary pancreatitis
Cholelithiasis, cholangitis, and biliary pancreatitis

Cholelithiasis: the presence of gallstones within the gall bladder
Cholangitis: ascending biliary tract infection (orange shading) secondary to choledocholithiasis
Biliary pancreatitis: Pancreatic outflow obstruction secondary to choledocholithiasis allows for activation of pancreatic zymogens, resulting in pancreatic inflammation (orange shading).


© AMBOSS

Epidemiology

  • Sex: ♀ > ♂ (2–3:1)
  • Prevalence: approx. 10–20% of the adult population in developed countries
  • Peak incidence: : > 40 years

References: [1][2]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

General

  • Imbalance in bile salts, lecithin (stabilizer), cholesterol, calcium carbonate, and bilirubin
  • Biliary stasis is a key component in gallstone formation.
  • Impaired gallbladder emptying (e.g., due to bowel rest, prolonged total parenteral nutrition, pregnancy; ) → biliary sludge → bile stasis (cholestasis)

Cholesterol stones [1][2]

  • Risk factors
    • Obesity, insulin resistance, dyslipidemia
    • Female sex
      • Especially during reproductive years due to increased levels of estrogen and progesterone
      • Increased estrogen levels cause increased secretion of bile rich in cholesterol, (lithogenic bile), which can result in the formation of cholesterol gallstones.
      • Increased progesterone levels cause smooth muscle relaxation, decreased gallbladder contraction, and subsequent bile stasis with formation of gallstones.
    • Multiparity or pregnancy
    • Age (> 40 years of age)
    • European, Native American, or Hispanic ancestry
    • Family history
    • Drugs: fibrates (inhibition of cholesterol 7-α hydroxylase), estrogen therapy, oral contraceptives
    • Malabsorption (e.g., Crohn disease, ileal resection, cystic fibrosis)
    • Rapid weight loss (e.g., after bariatric surgery)
  • Pathophysiology: abnormal hepatic cholesterol metabolism → ↑ cholesterol concentration in bile and ↓ bile salts and lecithin → hypersaturated bile → precipitation of cholesterol and calcium carbonate → cholesterol stones or mixed stones

During pregnancy, increased estrogen levels cause increased secretion of lithogenic bile (rich in cholesterol), resulting in the formation of cholesterol gallstones. Increased progesterone levels cause smooth muscle relaxation, decreased and impaired gallbladder contraction, and subsequent bile stasis and formation of gallstones.

Rule of the 6 Fs: Fat, Female, Fertile, Forty, Fair-skinned, Family history.

Black pigment stones [2][3][4]

  • Risk factors
    • Chronic hemolytic anemias (e.g., sickle cell disease, hereditary spherocytosis)
    • (Alcoholic) cirrhosis
    • Crohn disease
    • Total parenteral nutrition
    • Advanced age
  • Pathophysiology: ↑ hemolysis → increase in circulating unconjugated bilirubin → increased uptake and conjugation of bilirubin → precipitation of bilirubin polymers and stone formation

Mixed/brown pigment stones [2][3][4][5]

  • Risk factors: bacterial infections and parasites (e.g., Clonorchis sinensis, Opisthorchis species) in the biliary tract, sclerosing cholangitis [2]
  • Pathophysiology: infection or infestation → release of β-glucuronidase (by injured hepatocytes and bacteria) → hydrolyzes conjugated bilirubin and lecithin in the bile → increased unconjugated bilirubin and fatty acids → precipitation of calcium carbonate, cholesterol, and calcium bilirubinate (dark color) in bile

Pathophysiology for different types of gallstones
Pathophysiology for different types of gallstones

Cholesterol stones arise only in the gallbladder but can be transported into the cystic duct as well as the common bile duct and cause obstruction and stasis.

Pigmented gallstones contain varying amounts of calcium bilirubinate and can arise anywhere in the biliary tree. Black pigment stones arise mostly in the gallbladder (due to increased hemolysis; e.g., in sickle cell disease), whereas brown pigment stones typically arise in inflamed portions of the biliary duct (e.g., due to bacterial or parasitic infections).


© AMBOSS
Biliary disease and risk factors USMLE-style question walkthrough
Biliary disease and risk factors USMLE-style question walkthrough
© AMBOSS
Gallbladder with stones
Gallbladder with stones

The two larger gallstones in the neck of the gallbladder have an irregular consistency and yellowish-white to dark pigmentation, which indicates a high level of cholesterol. The stones located in the body and fundus are significantly smaller, darkly pigmented, and of different shapes, which is more suggestive of pigment stones due to bilirubin precipitation.


Source: “Gallstones” by Emmanuelm, Wikimedia Commons, licensed under CC BY 3.0.

Clinical features

  • Most gallstones are asymptomatic.
  • Biliary colic: constant, dull RUQ pain lasting < 6 hours
    • Especially postprandial: vagal stimulation (e.g., cholecystokinin release following a fatty meal) → gallbladder contraction → attempts to force the stone into the cystic duct
    • May radiate to the epigastrium, right shoulder, and back (referred pain)
  • Nonspecific symptoms
    • Nausea, vomiting, early satiety
    • Bloating, dyspepsia
  • Complications of cholelithiasis can be the first manifestation of gallstone disease.

Only a minority of patients with gallstones are symptomatic!

Diagnosis

Approach [2]

See “Cholelithiasis in pregnancy” for considerations in pregnant individuals.

  • Asymptomatic cholelithiasis : No diagnostic workup is required.
  • Suspected symptomatic cholelithiasis
    • Obtain imaging for cholelithiasis: biliary point-of-care ultrasound (POCUS) or transabdominal RUQ ultrasound
    • Rule out complications of cholelithiasis (e.g., acute cholecystitis or choledocholithiasis).
    • If the diagnosis remains unclear: See “Diagnosis of acute abdominal pain.”

Laboratory studies for suspected cholelithiasis

Laboratory studies are typically normal in uncomplicated cholelithiasis but should be ordered to rule out other acute biliary conditions and/or other causes of acute abdominal pain.

  • CBC: usually normal
  • LFTs: usually normal
  • Amylase, lipase: usually normal

Laboratory studies (e.g., WBC count, LFTs, lipase, amylase) are usually normal in uncomplicated cholelithiasis.

RUQ ultrasound for suspected cholelithiasis

If appropriately trained, consider performing a biliary POCUS.

  • Indication: best initial test in suspected symptomatic cholelithiasis [6][7]
  • Characteristic findings [6]
    • Cholelithiasis [8]
      • Intraluminal highly echogenic foci
      • Strong posterior acoustic shadowing
      • Rolling stone sign: movement of the echogenic foci with the changing of patient posture
    • Biliary sludge [9][10][11]
      • Low-level echogenic material in the dependent portion of the GB
      • No posterior acoustic shadowing
      • Slow movement with the changing of patient posture
  • Accuracy: operator- and technique-dependent [12]
    • RUQ ultrasound performed by a radiologist: ≥ 95% sensitivity and specificity for cholelithiasis
    • Biliary POCUS performed by emergency providers: ∼ 90% sensitivity and specificity for cholelithiasis

If appropriately trained, consider performing a biliary POCUS to rule in cholelithiasis. If the study is negative, further investigations (e.g., laboratory studies, RUQ ultrasound performed by a radiologist, additional imaging) may be necessary. [12]

Additional imaging studies

Additional imaging may be required if complications of cholelithiasis (e.g., acute cholecystitis, acute cholangitis, choledocholithiasis, biliary pancreatitis) cannot be ruled out, or to evaluate for other causes of abdominal pain.

MRI abdomen without and with IV contrast with MRCP [6]

  • Indications
    • Preferred second-line test if ultrasound findings are inconclusive
    • Suspected choledocholithiasis (see ''Diagnostics'' in choledocholithiasis for further details)
  • Supportive findings: well-defined hypointense (on T2) filling defect(s) within the gallbladder lumen [13]

CT abdomen with IV contrast [6]

  • Indications
    • Inconclusive ultrasound findings; MRI is not available
    • Suspected complications and/or differential diagnoses
    • Preoperative planning after confirming the diagnosis
  • Supportive findings (of radiopaque stones): well-defined hyperdense structure(s) within the gallbladder lumen
  • Disadvantages
    • Only radiopaque stones are detectable (15–20% of stones are radiopaque). [14][15]
    • Cannot detect the more common radiolucent pure cholesterol stones

Abdominal x-ray

  • Indication: usually not indicated in the evaluation of cholelithiasis, but may be performed as part of the workup of acute abdominal pain
  • Findings: gallstones with an outer radiopaque rim and radiolucent center [16]
  • Disadvantages: similar to those of CT scan

X-ray and CT scan are rarely diagnostic in cholelithiasis because only 15–20% of stones are radiopaque. Pure cholesterol stones are radiolucent.

Management of cholelithiasis and choledocholithiasis
Management of cholelithiasis and choledocholithiasis
© AMBOSS
Point-of-care ultrasound of the gallbladder
Point-of-care ultrasound of the gallbladder
© AMBOSS
Cholelithiasis
Cholelithiasis

Ultrasound right upper quadrant (oblique plane)

A solitary calculus (K) in the dependent gallbladder (G) has a reflective anterior surface (green overlay) and casts a posterior acoustic shadow (S; green hatched overlay).

Characteristic ultrasound findings of cholelithiasis include a reflective anterior surface, marked posterior acoustic shadowing, and movement during repositioning of the patient.

L: liver


Source: © IMPP
Cholelithiasis
Cholelithiasis

Transabdominal ultrasound (right upper quadrant)

Several well-defined, hyperechoic structures varying in size and shape (green overlay) are visible in the infundibulum and proximal body of the gallbladder (G). These structures are obstructing the passage of the ultrasound waves, resulting in posterior acoustic shadowing (hypoechoic area; hatched green overlay).

Hyperechoic intraluminal structures casting a posterior acoustic shadow are characteristic features of cholelithiasis.

L: liver


© AMBOSS
Gallbladder calculi and wall thickening
Gallbladder calculi and wall thickening

Ultrasound gallbladder (longitudinal plane)

Acoustic enhancement (green overlay) is seen distal to the gallbladder except where multiple small dependent hyperechoic calculi (yellow overlay) reflect the ultrasound beam and cast an acoustic shadow (green hatched overlay). Biliary sludge (yellow hatched overlay) is slightly hyperechoic compared to anechoic bile. The gallbladder wall is thickened (normal size: 1–2 mm) and has a layered appearance (red overlay), with central hypoechoic edema.

These findings in a patient with typical clinical features of RUQ pain strongly indicate acute calculous cholecystitis. Additional findings that would support a diagnosis of cholecystitis include an obstructing calculus, positive Murphy sign, pericholecystic fluid, gallbladder dilatation, and hyperemia of the gallbladder wall on color Doppler.

G: gallbladder; L: liver


Our great thanks to sono.gallery, a medical ultrasound library by Dr. Daniel Merkel, for providing the images and videos.
Cholelithiasis
Cholelithiasis

Ultrasound gallbladder (longitudinal plane)

Several dependent hyperechoic structures (green overlay) in the gallbladder lumen (G) absorb a portion of the ultrasound beam (dashed white line), resulting in posterior acoustic shadowing (hatched green overlay).

Gallbladder calculi are characteristically seen as mobile dependent hyperechoic intraluminal structures that produce acoustic shadowing. Shadowing is dependent on stone size, but independent of stone composition, calcium content, and shape.

L: liver; green outline: gallbladder wall


Our great thanks to sono.gallery, a medical ultrasound library by Dr. Daniel Merkel, for providing the images and videos.
Cholelithiasis and choledocholithiasis
Cholelithiasis and choledocholithiasis

Click on the overlay icon below the taskbar on the left to toggle the overlay on and off.

CT abdomen (with contrast; axial and coronal planes)

A laminated calcified calculus (red overlay) is present in the dilated gallbladder (green overlay), and a smaller calculus (yellow arrowhead) is seen in the distal common bile duct (blue overlay). A small gas-filled duodenal diverticulum (white arrowhead) is visible adjacent to the common bile duct calculus.

A cystic left ovarian lesion (yellow overlay) and numerous colonic diverticula (examples indicated by red arrowheads) are seen. There is extensive atherosclerotic calcification of the aorta (examples indicated by green arrowheads), coronary arteries, and several other arteries. A few subcentimeter hypodense lesions seen in the liver are likely cysts, and there is a small hiatal hernia.


Image source of original image: Radiologie Frechen-Erftstadt. Original title: “Cholecystolithiasis and choledocholithiasis”. Created by: Markus Le Blanc.
Gallbladder calculi
Gallbladder calculi

X-ray abdomen (AP view; supine position)

Multiple rounded calcified structures are visible in the right upper quadrant (black circle). Many have a laminated appearance, with a dense central calcification (green) surrounded by an inner lucent ring and outer calcified ring (white outline).

Pure cholesterol stones, the most common type of gallstone, are radiolucent on abdominal radiographs. Black pigment and mixed gallstones may contain sufficient calcium to be radiopaque.


Source: “StonesXray” by James Heilman, MD, Wikimedia Commons, licensed under CC BY-SA 3.0. The supplementary image with overlays of relevant areas was adapted from the image mentioned above and licensed under CC BY-SA 3.0.

Differential diagnoses

Differential diagnosis of RUQ pain

  • Abdominal (See also “Acute abdominal pain” and “Differential diagnosis of abdominal pain.”)
    • Choledocholithiasis
    • Acute cholecystitis
    • Acute cholangitis
    • Acute hepatic capsule swelling (e.g., acute hepatitis, perihepatitis, congestive hepatopathy)
    • Gastroesophageal reflux, gastritis, gastrointestinal ulcers
    • Early appendicitis
    • Acute pancreatitis
    • Right-sided diverticulitis
    • Sphincter of Oddi dysfunction
  • Extra-abdominal
    • Nephrolithiasis
    • Acute coronary syndrome (See also “Chest pain.”)
  • See also “Differential diagnosis of acute abdomen.”

Differential diagnoses of intraluminal gallbladder wall pathology

  • Cholangiocarcinoma
  • Gallbladder polyp

The differential diagnoses listed here are not exhaustive.

Treatment

Approach [2][17][18][19]

See “Cholelithiasis in pregnancy” for considerations in pregnant individuals.

  • Asymptomatic cholelithiasis
    • Expectant management is typically sufficient.
    • Consider the need for prophylactic cholecystectomy: See “Indications” in “Surgical Management.”
    • Patients with gallstones found incidentally during an ED visit can be referred back to their primary care physician for shared decision-making regarding surgical consult.
  • Symptomatic uncomplicated cholelithiasis
    • Treatment of biliary colic
      • Provide initial supportive therapy for acute biliary disease.
      • Counsel on lifestyle modifications to prevent further attacks (see “Nonoperative management of cholelithiasis” for details.)
    • Outpatient referral to general surgery for an elective cholecystectomy to prevent recurrence.
    • Consider surgical consult and admission if the pain is intractable.
  • Symptomatic complicated cholelithiasis
    • Admit for further management and consult general surgery and/or gastroenterology.
    • See “Acute cholecystitis,” “Acute cholangitis,” “Choledocholithiasis,” and “Biliary pancreatitis.”

Initial supportive therapy of acute biliary disease [17][19]

  • Bowel rest: NPO
    • In biliary colic: until the pain subsides (typically within a few hours) [17]
    • In other acute biliary conditions: The duration of NPO depends on the need for urgent interventional therapy
  • Analgesics [2]
    • NSAIDs: preferred first-line analgesics [2][20][21]
      • Ketorolac
      • Diclofenac
      • Ibuprofen
    • Opioids: for severe pain that does not improve with NSAIDs or in patients with contraindications to NSAIDs [2][22]
      • Morphine
      • Buprenorphine [2][23]
      • Meperidine [24][25]
      • See also “Pain management.”
  • Spasmolytics (e.g., dicyclomine ): consider as adjuvant therapy with analgesics in patients with severe pain [2][17]
  • Treatment for protracted vomiting
    • IV fluid therapy
    • Antiemetics
    • Consider NG tube insertion with suction.

Surgical management

  • Procedure: elective laparoscopic cholecystectomy
  • Indications
    • Symptomatic cholelithiasis
    • Asymptomatic cholelithiasis with any of the following:
      • Increased risk of gallbladder cancer (e.g., gallbladder polyps, porcelain gallbladder, gallstones ≥ 3 cm) [2][17][26]
      • Increased risk of developing complications (e.g., immunocompromised patients, multiple gallstones) [17][18]
      • Increased risk of becoming symptomatic (e.g., hemolytic anemia, patients undergoing gastric bypass surgery) [17][27][28]
  • Contraindication: suspected gallbladder cancer (see ''Treatment'' in “Biliary cancer”) [18][29]
  • Preoperative precautions: Assess for predictors of choledocholithiasis in all symptomatic patients (see ''Diagnosis of choledocholithiasis”). [30]
  • Timing: as early as possible in uncomplicated symptomatic cholelithiasis [2][31][32]
  • Complications: See “Complications of cholecystectomy”.

Cholecystectomy is usually not indicated in asymptomatic cholelithiasis.

Nonoperative management of cholelithiasis [2]

Indications

  • Patients at high risk of complications due to surgery or anesthesia (e.g., recent myocardial infarction)
  • Patients unwilling to undergo surgery

Expectant management [17]

  • Lifestyle modifications :
    • Low-fat diet (especially low in saturated fats) [33]
    • Avoid lithogenic drugs, such as estrogen, fibrates. [34]
    • Exercise regularly.
  • Follow-up: if symptoms recur

Oral bile acid dissolution therapy

  • May be useful in dissolving pure cholesterol stones (i.e., radiolucent stones) that are < 0.5 cm [17]
  • Ursodeoxycholic acid (off-label)
  • Duration of therapy: 6–24 months [17][33]
  • Advantage: symptomatic improvement even if stones are not completely dissolved [33]
  • Disadvantages
    • Ineffective in mixed stones
    • High recurrence rates [2]
    • Long duration of therapy
    • Requires repeat imaging to track treatment response

Extracorporeal shock wave lithotripsy (ESWL)

ESWL is also used in the treatment of nephrolithiasis.

  • Definition: : a noninvasive method of stone fragmentation using an acoustic pulse in the treatment of gallstones and pancreatic stones
  • Indication: typically used for solitary stones that can be localized well on imaging (radiolucent)
  • Procedure
    • Stones are localized using x-ray or ultrasound.
    • A lithotriptor generates shock waves that are focused on the stone, fragmenting it in the process.
    • Passage of stone fragments
      • Biliary stones: through the biliary system into the duodenum.
      • Pancreatic stones: through the pancreatic duct into the duodenum
  • Advantage: is noninvasive: and can be performed on an outpatient basis [2]
  • Disadvantages
    • Commonly causes biliary colic
    • Lower success rate in the presence of multiple stones
    • Risk of injury to adjacent solid organs (rare)
  • Prognosis: high recurrence rate (between 40 and 60% within 5 years) [35][36]

ESWL is contraindicated in pregnancy. [37]

Management of cholelithiasis and choledocholithiasis
Management of cholelithiasis and choledocholithiasis
© AMBOSS

Acute management checklist

  • Keep patient NPO.
  • Provide initial supportive therapy for acute biliary disease (e.g., analgesia, IV fluids, antiemetics).
  • Obtain RUQ ultrasound or perform biliary POCUS if available.
  • Identify and manage complications of cholelithiasis (e.g., acute cholecystitis, acute cholangitis, choledocholithiasis, biliary pancreatitis).
  • Refer to general surgery for an elective cholecystectomy to prevent recurrence.

Special patient groups

Cholelithiasis in pregnancy [38][39]

  • Cholelithiasis affects 12% of pregnant individuals. [40][41]
  • Incidentally detected cholelithiasis in asymptomatic individuals does not require further evaluation or management.
  • Symptomatic cholelithiasis manifests similarly in pregnant and nonpregnant individuals.
  • Additional differential diagnoses of cholelithiasis to consider in pregnant individuals include:
    • HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)
    • Acute fatty liver of pregnancy
    • Intrahepatic cholestasis of pregnancy

Diagnostics [38][39]

The diagnostic approach for cholelithiasis during pregnancy is similar to that for nonpregnant individuals, with the following additional considerations for imaging modalities.

  • Preferred initial imaging modality: RUQ ultrasonography
  • Diagnostic uncertainty: MRI without contrast [41][42][43]
  • Suspected choledocholithiasis: MRCP or endoscopic ultrasound (in consultation with a specialist) [38]

ALP levels can be elevated in pregnant individuals who do not have biliary disease because of placental ALP production. [44]

Management of symptomatic cholelithiasis in pregnancy [39][44]

  • Admit to the hospital for monitoring. [39]
  • Provide initial supportive management of acute biliary disease as in nonpregnant patients, but avoid NSAIDs.
  • Consult surgery for consideration of operative versus nonoperative management of cholelithiasis; use shared-decision making. [45]
    • Laparoscopic cholecystectomy may be preferred over conservative management. [38][39][45]
    • Consider corticosteroids to induce fetal lung maturity if indicated. [46]
    • Assess for risk factors for venous thromboembolism and provide appropriate VTE prophylaxis. [46]
  • For management of complications, see also “Acute pancreatitis during pregnancy” and “Acute cholecystitis in pregnancy.”

Do not delay emergency surgery (e.g., for complicated cholelithiasis) during pregnancy, regardless of the trimester. [45][46]

ERCP during pregnancy may be considered for the management of cholelithiasis complications (e.g., acute biliary pancreatitis, choledocholithiasis) if the benefits outweigh the risks of post-ERCP pancreatitis and fetal radiation exposure. [38]

Complications

General

  • Cholecystitis
    • Acute cholecystitis (most common)
    • Chronic cholecystitis
    • Porcelain gallbladder
  • Choledocholithiasis
  • Acute cholangitis
  • Acute biliary pancreatitis
  • Biliary-enteric fistula: Cholecystoenteric/choledochoenteric fistula (rare) , which can cause gallstone ileus (rare) [47][48]

Complications due to gallstone impaction at the gallbladder neck or infundibulum

Mirizzi syndrome [49][50]

  • Definition: extrinsic compression of the common bile duct (or any extrahepatic bile duct) by gallstone(s) impacted in the cystic duct or the infundibulum of the gallbladder [49][51]
  • Clinical features: similar to choledocholithiasis
  • Diagnostics: preferably ERCP/MRCP
    • Narrowing of the common hepatic duct
    • Stone within the cystic duct
    • Dilation of the intrahepatic biliary tree
  • Treatment
    • ERCP-guided CBD stent placement may be considered preoperatively to allow for biliary drainage. [52]
    • Open cholecystectomy may be preferred if diagnosed preoperatively. [50]
  • Complications [53][54]
    • Cholecystocholedochal fistula: an abnormal communication between the gallbladder and the common bile duct
    • Cholecystoenteric/choledochoenteric fistula (biliary-enteric fistula): an abnormal communication between the gallbladder or the CBD with the adjacent bowel
    • Gallstone ileus: due to biliary-enteric fistula

Gallbladder mucocele (gallbladder hydrops) [47][55]

  • Definition: marked distention of the gallbladder with sterile mucinous content due to chronic biliary outflow obstruction
  • Etiology [55]
    • Impacted gallstone at the gallbladder neck (most common)
    • Resolved acute cholecystitis [47]
    • Tumors at the gallbladder neck or CBD (e.g., GB polyps, cholangiocarcinoma, carcinoma of pancreatic head)
    • Acute inflammatory conditions (e.g., Kawasaki disease)
    • Extrinsic compression of the biliary outflow tract (e.g., lymphadenopathy, adhesions, strictures)
  • Pathophysiology: chronic biliary outflow obstruction → resorption of bile and secretion of mucin by biliary mucosa → collection of mucinous secretion within the gallbladder with no outflow → gross distention of the gallbladder
  • Clinical features: asymptomatic mass in the RUQ; no signs of infection
  • Diagnostics: (preferably ultrasound or CT); show grossly distended fluid-filled gall bladder without signs of inflammation [55]
  • Treatment
    • In children with no evidence of cholecystitis: trial of conservative management [56]
    • In adults: laparoscopic cholecystectomy [55]

We list the most important complications. The selection is not exhaustive.

Porcelain gallbladder
Porcelain gallbladder

X-ray abdomen (AP view)

A well-defined oval lesion is visible in the right upper quadrant of the abdomen, encapsulated in a thin rim of radiodense material, indicating intramural calcification of the gallbladder.

This is the typical appearance of porcelain gallbladder, which is a consequence of chronic gallbladder inflammation that is usually secondary to cholelithiasis.


Source: © IMPP
Porcelain gallbladder
Porcelain gallbladder

Ultrasound right upper quadrant (left: portal vein and common bile duct; right: gallbladder) of a patient with elevated liver enzymes

The left image shows normal directional blood flow within the portal vein (red) and a dilated common bile duct (CBD) with a diameter of 0.94 cm. The right image shows marked posterior shadowing (indicated by dashed lines) and deep to hyperechoic areas of calcification (yellow overlay) along the anterior gallbladder wall. Additional small hyperechoic areas (indicated by arrowheads) at the posterior right aspect of the image in the region of the gallbladder also proved to be wall calcifications on CT (not shown).

A hyperechoic gallbladder wall with posterior acoustic shadowing is seen with porcelain gallbladder. The appearance should be distinguished from a gallbladder filled with calculi, which produces the wall-echo-shadow sign.


Source: “Fig. 2 and 3, in: A Case Report on Detecting Porcelain Gallbladder form Wall-Echo-Shadow Sign on Point-of-Care Ultrasound” by Fares Al-Khouja; Proma Mazumde; John Moeller, JETem, licensed under CC BY 4.0. Modifications: - image is a product of two separate images - arrows removed. The supplementary image with overlays of relevant areas was adapted from the image mentioned above (© AMBOSS).
Choledocholithiasis with biliary obstruction
Choledocholithiasis with biliary obstruction

CT abdomen (with IV contrast; coronal plane)

Calculi are visible as hyperdense structures (green overlay) in the distal common bile duct (CBD). The CBD is dilated as a result of obstruction, and the distal duct shows inflammatory thickening (arrowheads).

GB: gallbladder; red overlay: gallbladder calculi


Source: “2 of 2, in: Choledocholithiasis” by Peña J, Journal of Education & Teaching in Emergency Medicine, licensed under CC BY 4.0. Modifications: arrow removed. The supplementary image with overlays of relevant areas was adapted from the image mentioned above (© AMBOSS). Further notes: Images courtesy of JETem.org
Cholelithiasis, cholangitis, and biliary pancreatitis
Cholelithiasis, cholangitis, and biliary pancreatitis

Cholelithiasis: the presence of gallstones within the gall bladder
Cholangitis: ascending biliary tract infection (orange shading) secondary to choledocholithiasis
Biliary pancreatitis: Pancreatic outflow obstruction secondary to choledocholithiasis allows for activation of pancreatic zymogens, resulting in pancreatic inflammation (orange shading).


© AMBOSS
Gallbladder mucocele
Gallbladder mucocele

Ultrasound abdomen (right upper quadrant; transverse plane)

The gallbladder (G; green outline) is grossly distended and filled with a heteroechoic fluid (yellow overlay) as evidenced by the fluid meniscus.

These findings in a patient with an asymptomatic right upper quadrant mass are characteristic of a gallbladder mucocele.

L: liver (which appears cirrhotic); A: ascites


Our great thanks to sono.gallery, a medical ultrasound library by Dr. Daniel Merkel, for providing the images and videos.
Gallbladder mucocele
Gallbladder mucocele

Ultrasound abdomen (right upper quadrant; longitudinal plane)

The gallbladder (green outline) appears grossly distended and filled with a heteroechoic fluid (yellow overlay) as evidenced by the fluid meniscus. Multiple small concretions (arrowheads) are visible within the fluid.

These findings in a patient with an asymptomatic right upper quadrant mass are characteristic of a gallbladder mucocele.

In this patient, carcinoma of the pancreatic head had obstructed biliary outflow, resulting in the gallbladder mucocele (which manifested as Courvoisier sign) and ascites due to peritoneal carcinomatosis.

L: liver; K: kidney; In: intestine; A: ascites


Our great thanks to sono.gallery, a medical ultrasound library by Dr. Daniel Merkel, for providing the images and videos.

External Resources

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