Cholecystitis and Biliary Colic



Peter A D Steel, MA, MBBS, Staff Physician, Department of Emergency Medicine, Joan and Sanford I Weill Medical College of Cornell and Columbia University College of Physicians and Surgeons, New York Presbyterian Hospitals

Nothing to disclose.


Rahul Sharma, MD, MBA, FACEP, Assistant Professor, Weill Medical College of Cornell University; Assistant Director for Operations, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center

Nothing to disclose.

Specialty Editor(s)

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Nothing to disclose.

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine

eMedicine Salary Employment

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

Nothing to disclose.

Samuel M Keim, MD, Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine

Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center

Nothing to disclose.


Biliary colic and cholecystitis are in the spectrum of biliary tract disease. This spectrum ranges from asymptomatic gallstones to biliary colic, cholecystitis, choledocholithiasis, and cholangitis.

Gallstones can be divided into 2 categories: Cholesterol stones (80%) and pigment stones (20%). Most patients with gallstones are asymptomatic. Stones may temporarily obstruct the cystic duct or pass through into the common bile duct, developing symptomatic biliary colic, developing in 1-4% of patients with gallstones annually. Cholecystitis occurs when obstruction at the cystic duct is prolonged (usually several hours) resulting in inflammation of the gallbladder wall. Acute cholecystitis develops in approximately 20% of patients with biliary colic if they are left untreated.[1] Choledocholithiasis occurs when the stone becomes lodged in the common bile duct, with the potential sequelae of cholangitis and ascending infections.

Biliary sludge is a reversible suspension of precipitated particulate matter in bile in a viscous mucous liquid phase. The most common precipitates are cholesterol monohydrate crystals and various calcium-based crystals, granules, and salts.[2] A portion of biliary sludge contains comparatively large particles (1-3 mm) called microliths, the formation of which is an intermediate step in the formation of gallstones (about 12.5%).[3]


Cholecystitis is inflammation of the gallbladder wall caused by obstruction of the cystic duct. This inflammation may be sterile or bacterial. Gallstones usually (>90%) cause this obstruction (calculous cholecystitis) but may infrequently be acalculous or caused by sludge (1.7%).[3] This obstruction results in gallbladder distention, gallbladder wall edema, and ischemia. Inflammatory mediators, specifically prostaglandins, are released, resulting in increased gallbladder inflammation. The wall of the gallbladder may undergo necrosis and gangrene (gangrenous cholecystitis) and ultimately perforate, with the development of an abscess in the right upper quadrant or liver or generalized peritonitis.

Bacterial infection is thought to be a consequence, not a cause, of cholecystitis. In the early stages of acute cholecystitis, bile is sterile. Approximately 20-75% of bile cultures are eventually positive, with the most common organisms being Escherichia coli and Klebsiella, Enterococci, and Enterobacter species. Bacterial superinfection with gas-forming organisms may lead to gas in the wall or lumen of the gallbladder (emphysematous cholecystitis).

Common bile duct stones (choledocholithiasis, 10%) are either secondary (from the gallbladder) or primary (formed in bile ducts).



United States

Prevalence of cholelithiasis is affected by many factors, including race, ethnicity, gender, age, medical problems, and fertility. Between 10% and 20% of adults (approximately 20 million people) in the United States have gallstones, which result in direct costs of more than $6.3 billion.[1, 4] Each year, only 1-3% of people with stones develop biliary colic. Acute cholecystitis eventually develops in about 20% of these symptomatic patients if they are left untreated.[5]


People of Hispanic or northern European countries are more likely to have stones.








Risk factors for biliary colic and cholecystitis include pregnancy, elderly population, obesity,

certain ethnic groups (Northern European and Hispanic), weight loss, and liver transplant patients.[11]

Risk factors for acalculous cholecystitis include diabetes, HIV, vascular disease, total parenteral nutrition, prolonged fasting, or being an ICU patient.

Drugs associated with cholecystitis include octreotide and ceftriaxone.[12, 13]

Laboratory Studies

Imaging Studies

Ultrasonography and nuclear medicine studies are the best imaging studies for the diagnosis of both cholecystitis and cholelithiasis. Ultrasonography is usually favored as the first test, whereas hepatobiliary scintigraphy is usually reserved for the 20% of patients in whom the diagnosis is unclear after ultrasonography has been performed.

Plain radiography, CT scans, and endoscopic retrograde cholangiopancreatography (ERCP) are diagnostic adjuncts.

Abdominal radiographs

The advantages of abdominal radiographs include their readily availability and low cost. However, abdominal radiographs have low sensitivity and specificity in evaluating biliary system pathology, but they can be helpful in excluding other abdominal pathology such as renal colic, bowel obstruction, perforation. Between 10 and 30% of stones have a ring of calcium and, therefore, are radiopaque. A porcelain gallbladder also may be observed on plain films.

Emphysematous cholecystitis, cholangitis, cholecystic-enteric fistula, or postendoscopic manipulation may show air in the biliary tree. Air in the gallbladder wall indicates emphysematous cholecystitis due to gas-forming organisms such as clostridial species and Escherichia coli.

Computed tomography scan

CT scan is not the test of choice and is recommended only for the evaluation of abdominal pain if the diagnosis is uncertain. CT scan can demonstrate gallbladder wall edema, pericholecystic stranding and fluid, and high-attenuation bile.

A helical CT scan with fine cuts through the biliary tract has not been well studied and may be useful.

Advantages of CT include the following:

Disadvantages of CT include the following:


View Image

The ultrasound only shows gallstones within the gallbladder but no evidence of cholecystitis (ie, gallbladder wall thickening, pericholecystic fluid, ....

Ultrasonography is the most common test used in the ED for the diagnosis of biliary colic and acute cholecystitis. It is 90-95% sensitive for cholecystitis and 78-80% specific. For simple cholelithiasis, it is 98% sensitive and specific.

Ultrasonography may be diagnostic for biliary disease, help exclude biliary disease, or may reveal alternative causes of the patient's symptoms.

Findings include gallstones or sludge and one or more of the following conditions:

Some ED sonographers recommend the diagnosis of cholecystitis if both a sonographic Murphy sign and gallstones (without evidence of other pathology) are present.

In a study by Ralls et al, involving 497 patients with suspected acute cholecystitis, the positive predictive value of the presence of stones and a positive ultrasonographic Murphy's sign was 92%, and that of stones and thickening of the gallbladder wall was 95%. The negative predictive value of the absence of stones combined with either a normal gallbladder wall or a negative Murphy's sign was 95%.[14]

Additional findings in the presence or absence of gallstones: Dilated common bile duct or dilated intrahepatic ducts of the biliary tree indicate common bile duct stones. In the absence of stones, a solitary stone may be lodged in the common bile duct, a location difficult to visualize sonographically.

Advantages of sonography include the following:

Disadvantages of sonography include the following:

Biliary scintigraphy

Depending on the ED, either sonography or nuclear medicine testing is the test of choice for cholecystitis. HIDA scans have sensitivity (94%) and specificity (65-85%) for acute cholecystitis. They are sensitive (65%) and specific (6%) for chronic cholecystitis. Oral cholecystography is not practical for the ED.

HIDA and diisopropyl iminodiacetic acid (DISIDA) scans are functional studies of the gallbladder. Technetium-labeled analogues of iminodiacetic acid (IDA) or diisopropyl IDA-DISIDA are administered intravenously (IV) and secreted by hepatocytes into bile, enabling visualization of the liver and biliary tree.

Normal scans are characterized by normal visualization of gallbladder in 30 minutes.

With cystic duct obstruction (cholecystitis), the HIDA scan shows nonvisualization (ie, considered positive) of the gallbladder at 60 minutes and uptake in the intestine as the bile is excreted directly into the duodenum. This finding has a sensitivity of 80-90% for acute cholecystitis.

Obstruction of the common bile duct causes nonvisualization of the small intestine.

The rim sign is a blush of increased pericholecystic radioactivity, tracer adjacent to the gallbladder, present in approximately 30% of patients with acute cholecystitis and in 60% with acute gangrenous cholecystitis.

False-negative results (filling in 30 min) are found in 0.5% of studies, and filling between 30-60 minutes is associated with false-negative rates of 15-20%.

False-positive results (10-20%) occur when the gallbladder does not visualize despite a nonobstructed cystic duct. Causes include fasting patients receiving total parenteral nutrition; severe liver disease, which leads to abnormal uptake of the tracer; cystic-duct obstruction induced by chronic inflammation, and biliary sphincterotomy, which decreases resistance to bile flow leading to excretion of the tracer into the duodenum. The specificity of the test can be improved by intravenous administration of morphine, known as morphine cholescintigraphy, which induces spasm of this sphincter, increasing back pressure to fill the gallbladder.[15]

Advantages of HIDA/DISIDA scans include the following:

Disadvantages of HIDA/DISIDA scans include the following:

Other Tests


ST-segment elevations are an uncommon finding in acute cholecystitis. The pathophysiological mechanism of these ECG changes is unclear but has been shown to be correctable with appropriate hepatobiliary management. Prompt recognition of cholecystitis will prevent the performance of unnecessary diagnostic and therapeutic cardiac interventions.[16]

Endoscopic retrograde cholangiopancreatography

ERCP provides both endoscopic and radiographic visualization of the biliary tract. It can be diagnostic and therapeutic by direct removal of common bile duct stones.

Ultrasonography is 50-75% sensitive for choledocholithiasis. CT and HIDA scans are not better. Therefore, when a dilated common bile duct is found or elevated LFTs are present, suspicion should remain high for common bile duct stones, and an ERCP should be considered.

Debate exists as to when an ERCP should be performed. In general, since cholecystitis is caused by obstruction of the ducts, the risk of common bile duct stones is approximately 10%. Given its potential for complications, ERCP should be used when there is a high potential for intervention and it should not be used solely as a diagnostic modality.

Some studies have classified people as low risk for common bile duct stones based on (1) lack of jaundice, (2) elevated transaminase levels, and (3) a common bile duct diameter of less than 8 mm. In this population, the risk of common bile duct stones may be as low as 1%. In patients with any of the risk factors, the rate of stones was 39%. Therefore, in general, people with any of the risk factors for common bile duct stones should undergo operative or ERCP evaluation of the common bile duct.

Major complications of ERCP include pancreatitis and cholangitis.

Prehospital Care

Patients with gallbladder colic or cholecystitis usually present in the prehospital setting with severe abdominal pain. Transport patients with minor symptoms to the hospital with an IV in place and monitor. However, the diagnosis of cholecystitis is not a prehospital diagnosis.

In patients with severe pain (eg, differential includes abdominal aortic aneurysm, myocardial infarction) and in patients with hypotension and/or fever who may have cholecystitis or cholangitis, prehospital care should include the following:

Emergency Department Care

Primary goal of ED care is stabilization of the patient and an expedient diagnosis.


Medication Summary

Although surgical therapy is treatment of choice for acute cholecystitis, many patients require hospitalization for stabilization and "cooling off" of the gallbladder prior to surgery. Indications for urgent surgical intervention include patients with complications such as empyema, emphysematous cholecystitis, or perforation. Medical therapy of gallbladder colic includes antiemetics and pain control. In mild cholecystitis, in which inflammation is the primary process, antibiotics are prophylactic but usually are used. In acute cholecystitis, broad-spectrum antibiotic coverage is used.

The following dosages are general recommendations. Please check current sources prior to administration.

Class Summary

Antispasmodics and anticholinergics are thought to decrease gallbladder and biliary tree tone, which decreases pain associated with gallstones.

Dicyclomine hydrochloride (Bentyl)

Clinical Context:  Has antimuscarinic and anticholinergic effects on smooth muscle. Moderately effective in reducing pain of gallbladder colic and cholecystitis. Used in many institutions as first-line pain control for this disease, with narcotics as second-line pain controllers. May not be given IV.

Glycopyrrolate (Robinul)

Clinical Context:  Use similarly to dicyclomine for anticholinergic effects. Acts in smooth muscle, CNS, and secretory glands, where blocks action of acetylcholine at parasympathetic sites.

Class Summary

When dicyclomine (Bentyl) is not effective, a narcotic is appropriate. The narcotic of choice is meperidine due to potential problems of increased tone of sphincter of Oddi with morphine.

Meperidine (Demerol)

Clinical Context:  Narcotic analgesic with multiple actions similar to those of morphine. However, may produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.

Class Summary

Cholecystitis and particularly obstruction of common bile duct can cause nausea and vomiting; therefore, antiemetics can be helpful.

Promethazine HCl (Phenergan, Anergan, Prorex)

Clinical Context:  Antidopaminergic agent effective in treatment of emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system.

Prochlorperazine (Compazine)

Clinical Context:  Antidopaminergic drug that blocks postsynaptic mesolimbic dopamine receptors, has anticholinergic effect, and can depress reticular activating system, possibly responsible for relieving nausea and vomiting.

Class Summary

Treatment of acute cholecystitis usually requires single-agent therapy, but for more serious infections, combination drug treatment has increased broad-spectrum coverage. Debate exists as to whether the most effective antibiotics must have high biliary concentrations. Antibiotics should be guided to target the most common organisms found in biliary tract pathology. These include E coli, Klebsiella species, and Streptococcus species.

Single-agent regimens include the following: piperacillin and tazobactam, ampicillin and sulbactam, mezlocillin, imipenem, meropenem, ticarcillin, and clavulanate.

Good combinations include the following: penicillin (including piperacillin, ampicillin, or penicillin) and metronidazole; the above plus an aminoglycoside (gentamicin or tobramycin); and aminoglycoside and third-generation cephalosporin.

Piperacillin/tazobactam (Zosyn)

Clinical Context:  Drug combination usually used in combination therapy. Antibiotic regimen needs to cover enteric microbes, including most common organisms: E coli (39%), Klebsiella species (54%), Enterobacter (34%), enterococci (34%), and group D streptococci.

Mezlocillin (Mezlin)

Clinical Context:  During growth phase, interferes with bacterial cell wall synthesis, causing death in susceptible microorganisms. Has antipseudomonal activity.

Imipenem and cilastatin (Primaxin)

Clinical Context:  For treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated due to potential for toxicity. Reserve for very ill patients. May be used alone or in combination.

Cefoxitin (Mefoxin)

Clinical Context:  Second-generation cephalosporin indicated for management of infections caused by susceptible gram-positive cocci and gram-negative rods. Many infections caused by gram-negative bacteria, resistant to some cephalosporins and penicillins, respond to cefoxitin.

Gentamicin (Gentacidin, Garamycin)

Clinical Context:  Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes.

Single daily dosing has not been well studied in cholangitis. Do not use if evidence of renal insufficiency exists.

Further Inpatient Care

Further Outpatient Care


Some literature supports dietary modification of decreased fat intake to decrease occurrence of biliary colic.


Complications of cholecystitis and/or biliary colic may include the following:



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The ultrasound only shows gallstones within the gallbladder but no evidence of cholecystitis (ie, gallbladder wall thickening, pericholecystic fluid, common bile duct dilatation, sonographic Murphy sign).