STEPTRACKERGASTROINTESTINAL | PATHOLOGY + PHYSIOLOGY | HIGH-YIELD REVIEW

Gallbladder & Biliary Stones

How stones form, where they lodge, and what each blockage looks like — from biliary colic to cholangitis to cancer.

FOCUS ON
Stone in the cystic duct: colic (transient) or cholecystitis (persistent, fever, Murphy sign, normal bilirubin). Stone in the common bile duct: jaundice, ↑ ALP (choledocholithiasis), plus fever = cholangitis (Charcot triad). Stone at the ampulla → pancreatitis. Stone through a fistula → gallstone ileus.
DISORDER
MECHANISM · RISK
FEATURES
CLUE · DIAGNOSIS
Cholesterol stones
most common
Bile supersaturated with cholesterol (↑ cholesterol or ↓ bile salts/lecithin) + gallbladder stasis
Yellow, radiolucent; female, obesity, pregnancy/estrogen, age 40+, rapid weight loss, fibrates, ileal disease, Native American ancestry
"Female, fat, fertile, forty"
Black pigment stones
↑ unconjugated bilirubin → calcium bilirubinate
Small, radiopaque; chronic hemolysis (sickle cell, spherocytosis), cirrhosis, TPN
Gallstones in a child → hemolysis
Brown pigment stones
Bacterial β-glucuronidase deconjugates bilirubin
Soft, radiolucent; form in ducts; biliary infection, Clonorchis (East Asia)
Recurrent cholangitis
Biliary colic
Gallbladder contracts (CCK after fatty meal) against a stone briefly blocking the cystic duct
Postprandial RUQ/epigastric pain, resolves within hours; normal labs
Ultrasound: stones
Acute cholecystitis
Stone impacted in the cystic duct → distension, chemical then bacterial inflammation
RUQ pain > 6 h, fever, ↑ WBC, Murphy sign, pain referred to right scapula (phrenic)
US: thick wall, fluid · HIDA: gallbladder not seen · bilirubin usually normal
Acalculous cholecystitis
Stasis + ischemia in the critically ill (burns, trauma, sepsis, TPN); CMV in AIDS
Fever, RUQ tenderness in an ICU patient
High risk of gangrene, perforation
Choledocholithiasis
Stone in the common bile duct
Jaundice, ↑ ALP, GGT, conjugated bilirubin; may cause pancreatitis
ERCP removes the stone
Ascending cholangitis
CBD obstruction + infection (E coli, Klebsiella, Enterococcus)
Charcot triad: fever, jaundice, RUQ pain · Reynolds pentad: + hypotension, confusion
Antibiotics + urgent ERCP drainage
Gallstone ileus
Cholecystoenteric fistula → large stone passes and lodges at the ileocecal valve
Small bowel obstruction in an older woman; air in the biliary tree (pneumobilia)
Rigler triad
Mirizzi syndrome
Stone in the gallbladder neck/cystic duct compresses the common hepatic duct
Obstructive jaundice without a CBD stone
Can erode into the duct
Gallbladder carcinoma
Adenocarcinoma; gallstones, porcelain gallbladder (calcified wall), Native American ancestry
Older women; vague RUQ pain, weight loss, jaundice when advanced
Poor prognosis · porcelain GB → cholecystectomy

Mechanism — where the stone sits decides the disease

GallbladderSilent stones
→
Cystic ductColic · cholecystitis
→
Common bile ductJaundice · cholangitis
→
AmpullaPancreatitis

Bilirubin rises only when the common duct is blocked. A stone in the cystic duct leaves bile flow from the liver intact.

Gallstone types

TYPE
X-RAY
CAUSE
WHERE
Cholesterol
Radiolucent
Supersaturation, stasis
Gallbladder
Black pigment
Radiopaque
Hemolysis, cirrhosis
Gallbladder
Brown pigment
Radiolucent
Infection, parasites
Bile ducts
Mixed
Variable
Most stones in practice
Gallbladder

How it's tested

COMMON CONFUSIONCholecystitis gives fever and a Murphy sign with normal bilirubin. Cholangitis adds jaundice because the common duct is blocked and infected.
THE TRAPA child or young adult with gallstones has a hemolytic disease (sickle cell, hereditary spherocytosis) until shown otherwise — they are black pigment stones.
YOUR APPROACHPain pattern + fever + bilirubin/ALP → which duct → imaging (US first; HIDA if unclear) → treatment (cholecystectomy, ERCP, antibiotics).

If you see… think…

Obese 40-year-old woman, RUQ pain after fatty meals, resolves → biliary colic
Fever, persistent RUQ pain, inspiratory arrest on palpation → acute cholecystitis
Nonvisualized gallbladder on HIDA scan → cystic duct obstruction
Burn patient in ICU with fever and RUQ tenderness, no stones → acalculous cholecystitis
Jaundice, ↑ ALP, dilated common bile duct → choledocholithiasis
Fever + jaundice + RUQ pain + hypotension + confusion → Reynolds pentad — cholangitis
Bowel obstruction + air in the biliary tree → gallstone ileus
Child with sickle cell disease and radiopaque stones → black pigment stones
Calcified gallbladder wall on X-ray → porcelain gallbladder — cancer risk
Pain after meals referred to the right shoulder blade → phrenic irritation from gallbladder