Snapshot A 46-year-old woman presents to her primary care physician for recurrent right upper quadrant pain. She reports 30-minute episodes of abdominal pain after eating meals, especially with fast food meals. She has not had any fevers or chills, and her episodes always resolve. Her past medical history includes hyperlipidemia, morbid obesity, and polycystic ovarian syndrome, for which she takes oral contraceptives. Her physician orders a right upper quadrant ultrasound, which shows gallstones without any wall thickening. Her physician recommends conservative measures for now, including dietary changes. Introduction Clinical definition cholelithiasis stones in gallbladder are cholesterol or pigment stones biliary colic right upper quadrant abdominal pain following meals, usually associated with nausea and vomiting that self-resolves occurs particularly after fatty or heavy meals (secondary to cholecystokinin (CCK) release) or at night Associated conditions acute cholecystitis ascending cholangitis acute pancreatitis gallstone ileus Epidemiology Demographics female > male adults Risk factors cholesterol stones (most common) F’s login to view 4 more bullets impaired gallbladder emptying login to view 3 more bullets biliary stasis login to view 1 more bullet Native American heritage pigment stones cirrhosis biliary stasis chronic hemolysis ETIOLOGY Pathogenesis cholesterol saturation can cause impaired gallbladder motility gallstones can lead to mechanical obstruction of biliary tract and cause bacterial overgrowth Presentation Symptoms cholelithiasis may be asymptomatic biliary colic colicky pain in right upper quadrant may radiate to the right shoulder triggered by fatty or heavy foods episodes self-resolve Studies Diagnostic testing diagnostic approach gallstones may be found incidentally on abdominal imaging imaging right upper quadrant ultrasound login to view 2 more bullets magnetic resonance cholangiopancreatography (MRCP) login to view 2 more bullets endoscopic retrograde cholangiopancreatography (ERCP) login to view 3 more bullets studies alkaline phosphatase and bilirubin may be elevated but only mildly amylase login to view 1 more bullet Diagnostic criteria gallstones on imaging Differential Peptic ulcer disease distinguishing factors epigastric gnawing pain that may improve with meals ultrasound will show no signs of biliary disease Sphincter of Oddi dysfunction distinguishing factors presents similarly to biliary colic diagnosed with manometry treated with sphincterotomy via ERCP Treatment Management approach incidental asymptomatic gallstones do not require any treatment antibiotics are not needed for simple cholelithiasis and biliary colic First-line supportive care analgesia login to view 1 more bullet diet login to view 1 more bullet rehydration elective cholecystectomy indications login to view 5 more bullets Second-line ursodeoxycholic acid indication login to view 4 more bullets Complications Secondary infections