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Biliary disease
Colic, cholecystitis or cholangitis — the treatment is very different. Separate simple biliary colic from inflamed gallbladder (cholecystitis) and infected bile duct (cholangitis). Cholangitis is the killer: it needs antibiotics and drainage. Built for revision, not live patient decisions.
Settle them, and check the basics
which one is it?Red flags — what each should make you think
Charcot's triad (fever, jaundice, RUQ pain) is present in only about half of cholangitis cases. Any patient with gallstones who has a fever and deranged LFTs should be treated as cholangitis until proven otherwise.
First actions
- 💊Analgesia + antiemetic
- 🩸Bloods
- USSAbdominal ultrasound
- ℞Antibiotics if infected
- IVFluids if septic
- ☎Surgical / GI team
Understand the patient
the biliary spectrumThe spectrum
- Biliary colic — RUQ/epigastric pain, often after fatty food, settles within hours; no fever, normal bloods
- Acute cholecystitis — persistent pain, fever, Murphy's sign, raised WCC/CRP; USS: thick wall, pericholecystic fluid, stones
- Choledocholithiasis — stone in the CBD: jaundice, obstructive LFTs, dilated duct
- Cholangitis — infection behind an obstructed duct: fever, jaundice, RUQ pain (Charcot's); add shock and confusion (Reynolds' pentad)
- Gallstone pancreatitis — see the pancreatitis page
Treatment (NICE CG188, Tokyo guidelines)
- Cholecystitis — antibiotics, analgesia; laparoscopic cholecystectomy within 1 week of diagnosis (NICE); percutaneous cholecystostomy if unfit
- Cholangitis — antibiotics + biliary drainage (ERCP); urgency by severity: severe/organ dysfunction → urgent; moderate → early (within 24–48 h)
- CBD stones — ERCP or surgical bile duct clearance with cholecystectomy
- Biliary colic — analgesia, elective cholecystectomy
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Fever, rigors, jaundice, RUQ pain; hypotension and confusion in severe cases.
LFTs (obstructive), USS (dilated CBD), cultures; MRCP if unclear.
Sepsis bundle, IV antibiotics, urgent ERCP for drainage (or PTC if ERCP not possible).
Severe or worsening cholecystitis, sepsis, peritonism; diabetics and elderly.
CT.
Urgent cholecystectomy or percutaneous drainage.
Epigastric pain to back, raised lipase.
Lipase, USS.
See the pancreatitis page.
Epigastric pain with ECG changes; right basal pneumonia.
ECG, troponin, CXR.
Treat the real cause.
Investigate — what to order, when, and what it tells you
test with a question in mindBloods
USS
MRCP
ECG
How the plan comes together
disposition · handoverhome
Biliary colic, pain settled, normal bloods: analgesia, low-fat diet advice, surgical outpatient referral for cholecystectomy.
admit / ERCP
Cholecystitis, CBD stones, cholangitis, pancreatitis.
Hand over: diagnosis, LFT trend, USS findings, antibiotic, ERCP/cholecystectomy plan.
Colic settles, cholecystitis needs antibiotics and early surgery, and cholangitis needs antibiotics plus drainage, urgently. Fever and deranged LFTs mean cholangitis until proven otherwise. Nicely done getting here.
Clerking template
copy or downloadBiliary disease — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 10 knownFrequently asked questions
quick answersWhat are the red flags for gallstone disease (biliary colic, cholecystitis, cholangitis)?
- Fever + jaundice + RUQ pain — think ascending cholangitis
- Hypotension, confusion + Charcot's triad — think severe cholangitis (Reynolds' pentad)
- Persistent RUQ pain, fever, Murphy's positive — think acute cholecystitis
- Jaundice, dilated CBD — think choledocholithiasis
- Epigastric pain, raised lipase — think gallstone pancreatitis
- Older patient with obstruction + air in biliary tree — think gallstone ileus
What is the initial management of gallstone disease (biliary colic, cholecystitis, cholangitis)?
- Analgesia + antiemetic — —
- Bloods — FBC, CRP, LFT, lipase/amylase, U&E, clotting, cultures if febrile
- Abdominal ultrasound — stones, gallbladder wall, CBD diameter
- Antibiotics if infected — cholecystitis/cholangitis — per local policy
- Fluids if septic — sepsis bundle
- Surgical / GI team — ERCP if cholangitis
Always alongside senior support and your local guideline.
What diagnoses must you not miss in gallstone disease (biliary colic, cholecystitis, cholangitis)?
- Ascending cholangitis — fever + jaundice
- Gangrenous / perforated gallbladder — worsening cholecystitis
- Gallstone pancreatitis — lipase raised
- Inferior MI / pneumonia (mimics) — upper abdominal pain
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for gallstone disease (biliary colic, cholecystitis, cholangitis)?
- Bloods — Obstructive pattern (raised ALP, GGT, bilirubin) suggests CBD stone.
- USS — Stones, wall thickening, pericholecystic fluid, CBD diameter.
- MRCP — Suspected CBD stones with non-diagnostic USS.
- ECG — Upper abdominal pain can be inferior MI.
Admit or discharge: how is the plan decided for gallstone disease (biliary colic, cholecystitis, cholangitis)?
- Home — Biliary colic, pain settled, normal bloods: analgesia, low-fat diet advice, surgical outpatient referral for cholecystectomy.
- Admit / ercp — Cholecystitis, CBD stones, cholangitis, pancreatitis.
Is there a clerking template for gallstone disease (biliary colic, cholecystitis, cholangitis)?
Yes — there is a free clerking template for gallstone disease (biliary colic, cholecystitis, cholangitis) on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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