Symptomatic cholelithiasis means gallstones that cause biliary colic, a steady pain that appears when a stone briefly blocks the gallbladder outlet. The pain usually settles within a few hours, while longer pain with fever points to a complication such as cholecystitis.
Key symptoms
- Steady right upper or upper middle abdominal pain
- Pain after fatty meals, often at night, lasting less than 6 hours
- Pain spreading to the right shoulder or back
- Nausea and vomiting
What you find on exam
- Right upper quadrant tenderness during an attack
- No fever and no jaundice in simple colic
- Negative or mild Murphy sign between attacks
- Jaundice or fever suggest a complication
Tests
- Right upper quadrant ultrasound: stones with acoustic shadowing
- Liver tests, bilirubin and lipase
- Blood count to look for infection
- MRCP or endoscopic ultrasound if a bile duct stone is suspected
Treatment basics
- Pain control with an NSAID such as ketorolac
- Elective laparoscopic cholecystectomy
- Low-fat diet while waiting for surgery
- Ursodiol only for selected patients who cannot have surgery
Red flags
- Pain longer than 6 hours with fever (acute cholecystitis)
- Jaundice, fever and right upper pain (cholangitis)
- Epigastric pain to the back with high lipase (gallstone pancreatitis)
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.