Last reviewed: March 2026
Contents
MDM Templates
Biliary Colic
Patient presents with episodic RUQ/epigastric pain that is postprandial in nature, consistent with biliary colic. Well appearing, afebrile. No Murphy sign. No jaundice.
History, exam, and labs not consistent with cholecystitis, pancreatitis, SBO, appendicitis, AAA, mesenteric ischemia, or other surgical abdomen. LFTs and lipase within normal limits.
Plan: Analgesia and antiemetic. Pain resolved in the ED.
Disposition: Discharge with outpatient surgical referral for elective cholecystectomy. Low-fat diet counseled. Return precautions for fever, persistent vomiting, worsening pain, or jaundice. Follow up with PCP within 1 week.
If recurrent biliary colic with known gallstones, imaging deferred after shared decision-making:
Patient with prior documented cholelithiasis and recurrent biliary colic. Pain pattern consistent with prior episodes. Given normal vitals, pain now controlled, and absence of concerning features, imaging deferred per shared decision-making. Instructed to follow up with surgery for cholecystectomy planning.
Acute Cholecystitis
Patient presents with RUQ pain, fever, and positive Murphy sign consistent with acute cholecystitis. Imaging confirms gallbladder wall thickening with pericholecystic fluid.
History, exam, and imaging not consistent with complicated cholecystitis (emphysematous, gangrenous, or perforated), cholangitis, pancreatitis, or hepatic abscess.
Plan: NPO, IV fluids, antibiotics initiated — ceftriaxone 2 g IV + metronidazole 500 mg IV. Analgesia. Surgery consulted for cholecystectomy.
Disposition: Admit to surgery.
If complicated cholecystitis (toxic, emphysematous, or gangrenous):
Patient with cholecystitis and signs concerning for complicated disease — ***. Broad-spectrum antibiotics initiated — piperacillin-tazobactam 3.375 g IV. Surgery consulted emergently. IV fluid resuscitation.
Disposition: Admit to surgery for emergent cholecystectomy.
Choledocholithiasis
Patient presents with RUQ pain and jaundice. Labs demonstrate elevated bilirubin and transaminases consistent with biliary obstruction from choledocholithiasis. Afebrile. No signs of cholangitis (no Charcot triad).
Plan: Analgesia, antiemetic, IV fluids. GI consulted for ERCP. Surgery consulted regarding cholecystectomy timing.
Disposition: Admit for ERCP and stone extraction.
Ascending Cholangitis
Patient presents with RUQ pain, fever, and jaundice — Charcot triad consistent with ascending cholangitis. Hemodynamically stable / unstable with ***.
This is a biliary emergency. Broad-spectrum antibiotics initiated — piperacillin-tazobactam 3.375 g IV. IV fluid resuscitation. GI consulted emergently for ERCP and biliary decompression. Surgery consulted.
If Reynolds pentad (Charcot triad + altered mental status + hypotension):
Patient with ascending cholangitis and septic shock — Reynolds pentad present. Aggressive fluid resuscitation, vasopressors as needed, broad-spectrum antibiotics. Emergent biliary decompression is indicated — ERCP preferred, percutaneous transhepatic cholangiography (PTC) if ERCP not available or fails.
Disposition: Admit to ICU.
Clinical Education
Diagnosis Pearls
Biliary colic is a misnomer — the pain is not colicky. It’s a steady, visceral ache in the RUQ or epigastrium lasting 30 minutes to several hours, often precipitated by fatty meals. If pain lasts >6 hours, think cholecystitis rather than colic.[1]
Murphy sign is the most useful exam finding for cholecystitis (positive LR ~2.8, negative LR ~0.5), but its absence doesn’t rule it out — particularly in the elderly, diabetics, and patients on steroids who may have blunted inflammatory responses.[2]
The sonographic Murphy sign (focal tenderness under the US probe over the gallbladder) has better test characteristics than the clinical Murphy sign and adds significant value to the bedside assessment.
Imaging Approach
RUQ ultrasound is the first-line imaging study. Findings of cholecystitis: gallbladder wall thickening (>3 mm), pericholecystic fluid, sonographic Murphy sign, gallstones or sludge. Sensitivity ~85%, specificity ~95% for acute cholecystitis.[3]
HIDA scan is the gold standard when US is equivocal. Non-visualization of the gallbladder at 4 hours (or 60 min with morphine augmentation) has >95% sensitivity for cholecystitis. Useful when clinical suspicion is high but US shows only gallstones without wall thickening.
CT is not first-line for biliary disease but identifies complications. It can show emphysematous cholecystitis (gas in the gallbladder wall — a surgical emergency), perforation, and biliary ductal dilation suggestive of choledocholithiasis.
Common bile duct >6 mm on US (or >8 mm in post-cholecystectomy patients) suggests choledocholithiasis. Combined with elevated bilirubin and transaminases, this warrants ERCP or MRCP.
Antibiotic Selection
| Scenario | Regimen |
| Uncomplicated cholecystitis | Ceftriaxone 2 g IV + metronidazole 500 mg IV |
| Complicated / septic | Piperacillin-tazobactam 3.375 g IV q6h |
| Cholangitis | Piperacillin-tazobactam 3.375 g IV q6h (or meropenem if prior resistant organisms) |
| Penicillin allergy | Ciprofloxacin 400 mg IV + metronidazole 500 mg IV |
Common biliary pathogens: E. coli, Klebsiella, Enterobacter, Enterococcus. Anaerobic coverage (metronidazole) is important in complicated cases.[4]
Cholangitis Pearls
Charcot triad (fever + RUQ pain + jaundice) is present in only ~50–70% of cholangitis cases. Reynolds pentad adds altered mental status and hypotension — this is cholangitis with septic shock and carries high mortality without emergent decompression.[5]
Biliary decompression is the definitive treatment — antibiotics alone are insufficient. ERCP with sphincterotomy and stone extraction is the procedure of choice. Timing depends on severity: mild cases can wait 24–48 hours; moderate to severe cases need ERCP within 24 hours; septic shock mandates emergent decompression.[5]
If ERCP is unavailable or fails, percutaneous transhepatic biliary drainage (PTBD) is the alternative. Surgical decompression (open common bile duct exploration) is the last resort.
Acalculous Cholecystitis
Acalculous cholecystitis accounts for 5–10% of acute cholecystitis cases and carries higher morbidity and mortality than calculous disease. It occurs primarily in critically ill patients (ICU, post-surgical, burns, TPN) due to gallbladder stasis and ischemia. Diagnosis is challenging — may present only as unexplained sepsis in an ICU patient. US findings are the same minus gallstones. HIDA scan is more useful when US is equivocal.[6]
Special Populations
Pregnancy: Biliary disease is the second most common non-obstetric surgical emergency in pregnancy. US is safe and first-line. Cholecystectomy is safe in the second trimester and increasingly performed laparoscopically in all trimesters when indicated. Do not delay necessary surgery — perforation risk from delayed treatment is worse than operative risk.[7]
Elderly: Atypical presentations are common — may lack fever, leukocytosis, or RUQ tenderness. Higher rates of complicated disease (gangrenous, emphysematous, perforated) at presentation because of delayed diagnosis. Maintain a low threshold for imaging.
Post-cholecystectomy pain: Recurrent RUQ pain after cholecystectomy warrants evaluation for retained common bile duct stones, bile duct injury, sphincter of Oddi dysfunction, or non-biliary etiologies (PUD, pancreatitis). CBD on US >8 mm is normal post-cholecystectomy — use clinical context.
Disposition
Admit if: Cholecystitis (for cholecystectomy), cholangitis (for ERCP), choledocholithiasis with significant biliary obstruction, complicated biliary disease, sepsis, or inability to tolerate PO.
Discharge if: Biliary colic with resolved pain, reassuring labs, tolerating PO, reliable follow-up with surgery for elective cholecystectomy. Patient should be counseled that recurrent episodes are likely without cholecystectomy and that complications increase with each episode.
References
- Trowbridge RL et al. Does this patient have acute cholecystitis? JAMA. 2003;289(1):80-86. PubMed
- Singer AJ et al. The utility of the Murphy sign in diagnosing cholecystitis. Acad Emerg Med. 1996;3(1):7-12.
- Bree RL. Further observations on the usefulness of the sonographic Murphy sign in the evaluation of suspected acute cholecystitis. J Clin Ultrasound. 1995;23(3):169-172. PubMed
- Solomkin JS et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and IDSA. Clin Infect Dis. 2010;50(2):133-164. PubMed
- Miura F et al. Tokyo Guidelines 2018: flowchart for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):55-72. PubMed
- Barie PS, Eachempati SR. Acute acalculous cholecystitis. Gastroenterol Clin North Am. 2010;39(2):343-357. PubMed
- Date RS et al. EAES consensus statement on acute appendicitis and cholecystitis in pregnancy. Surg Endosc. 2014;28(5):1589-1609.
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