GPAtlas🧭 When to suspect
Gallstones (cholelithiasis) are solid concretions that form in the gallbladder, usually from cholesterol. They are common – affecting around 10–15% of UK adults – and the majority are asymptomatic and need no treatment. Symptoms arise only when a stone obstructs the cystic duct or the common bile duct (CBD). Biliary colic is the pain of transient cystic-duct obstruction without inflammation or infection.
Suspect biliary colic in a patient with sudden, severe, episodic pain in the right upper quadrant (RUQ) or epigastrium, often triggered by a fatty meal, lasting from around 30 minutes to a few hours and then settling. It may radiate to the back, between the shoulder blades, or the right shoulder tip, with nausea or vomiting. Despite its name the pain is usually constant during an attack rather than truly colicky, and the patient is afebrile and well between episodes.
The central primary-care task is twofold: recognise uncomplicated biliary colic – which is managed with analgesia and routine referral – while never missing a complication (acute cholecystitis, choledocholithiasis, ascending cholangitis, or gallstone pancreatitis), each of which needs urgent admission.
Risk rises with the traditional "5 Fs" – Fat (obesity), Female (including combined oral contraceptive and HRT – hormone replacement therapy – use), Fertile (pregnancy and parity), Forty (risk climbs from around age 40 onwards), and Family history. Other contributors include rapid weight loss or prolonged fasting, diabetes, Crohn's disease or ileal resection, cirrhosis, haemolytic anaemia, and certain drugs – ceftriaxone, octreotide, fibrates, and GLP-1 (glucagon-like peptide-1) receptor agonists.
| Presentation | Distinguishing features |
|---|---|
| Biliary colic | Episodic RUQ/epigastric pain, minutes to a few hours, often post-fatty meal; settles fully; afebrile, normal bloods. |
| Acute cholecystitis | Persistent RUQ pain > 6 hours, fever, positive Murphy's sign, raised WCC/CRP. |
| Choledocholithiasis (CBD stone) | Jaundice, dark urine, pale stools; raised ALP and bilirubin (obstructive picture). |
| Ascending cholangitis | Charcot's triad – RUQ pain + fever/rigors + jaundice; add hypotension + confusion for Reynolds' pentad. A medical emergency. |
| Gallstone pancreatitis | Severe epigastric pain radiating to the back, vomiting, systemically unwell; raised amylase/lipase. |
Source: NICE CG188 · NICE QS104
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