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Gallstone disease may present as incidentally discovered asymptomatic cholelithiasis, biliary colic, cholecystitis, cholangitis, or pancreatitis. The pattern depends on the location of the stone and its chronicity (Figure 3-2). Biliary colic typically presents with episodes of intense abdominal pain that begin 1 hour or more after eating and commonly wake patients from sleep. The pain is usually located in the RUQ, although epigastric pain is also common. The pain may radiate to the back and may be associated with nausea and vomiting. The pain usually lasts for more than 30 minutes and may last for hours.


  1. Biliary colic

    1. Gallstones are commonly asymptomatic. Biliary colic occurs when a gallstone becomes lodged in the cystic duct and the gallbladder contracts against the obstruction.

    2. Annual risk of biliary colic in patients with asymptomatic gallstones is 1–4%.

    3. Risk factors for gallstone development

      1. Increasing age is the predominant risk factor. The prevalence is 8% in patients older than 40 years and 20% in those older than 60 years (Figure 3-3).

      2. Obesity

      3. Sex: women are affected more than men (risk increases during pregnancy), although the incidence in men is still significant (Figure 3-3).

      4. Gallbladder stasis (due to rapid weight loss, which may occur in patients on very low-calorie diets, on total parenteral nutrition, and after surgery)

      5. Other less common risk factors include family history, Crohn disease, and hemolytic anemias (eg, thalassemia, sickle cell disease), which can lead to increased bilirubin excretion and bilirubin stones.

    4. Presents as one of the classic visceral obstructive syndromes with severe, crampy waves of pain that incapacitate the patient.

    5. Characterized by episodes of pain with pain-free intervals of weeks to years.

    6. Pain begins 1–4 hours after eating or may awaken the patient during the night. May be precipitated by fatty meals.

    7. The pain is usually associated with nausea and vomiting.

    8. The pain usually lasts < 2–4 hours. An episode that lasts longer than 4–6 hours and is accompanied by fever or marked RUQ tenderness suggests cholecystitis has developed.

    9. Resolution occurs if the stone comes out of the cystic duct. The intense pain improves fairly rapidly, although mild discomfort may persist for 1–2 days.

    10. Prognosis

      1. Biliary colic recurs in 50% of symptomatic patients.

      2. Acute cholecystitis develops if the stone remains lodged in the cystic duct.

      3. Complications (eg, pancreatitis, acute cholecystitis, or ascending cholangitis) occur in 25% of patients who have experienced biliary colic.

    11. Colic occasionally develops in patients without stones secondary to sphincter of Oddi dysfunction or scarring leading to obstruction.

Figure 3-3.

Prevalence of asymptomatic gallstones by age. (Reproduced with permission from Bateson MC. Forttnightly review: Gallbladder disease, BMJ. 1999;June 26;318(7200):1745–1748.)


  1. Pain localized to the RUQ in 54% of patients and epigastrium in 34% of patients. It also may present as a band-like ...

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