GPAtlas🧭 When to suspect
Gallstones (cholelithiasis) are solid concretions that form in the gallbladder, usually from cholesterol.
• Gallstones are common – affecting around 10–15% of UK adults.
• 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.
• The pain is often triggered by a fatty meal.
• An attack lasts from around 30 minutes to a few hours and then settles.
• The pain 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.
• The patient is afebrile and well between episodes.
In primary care, 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).
• Family history.
Other contributors include rapid weight loss or prolonged fasting, diabetes, Crohn's disease or ileal resection, cirrhosis and haemolytic anaemia.
Certain drugs also raise the risk: 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 alkaline phosphatase (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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