Biliary Disease


  • Murphy’s sign: When palpating RUQ, have patient take deep breath simultaneously; Positive sign = cessation of inspiration secondary to pain
  • Sonographic Murphy’s: Maximal abdominal tenderness from pressure of the US probe over the visualized gallbladder; Does not have to do with inspiration!
  • Courvoisier’s signs: Palpable gallbladder on jaundiced patient
  • Porcelain Gallbladder: Calcification of galldbladder thought to be related to chronic cholecystitis; correlated with increased rate of malignancy

Biliary Colic:

  • Pathophysiology: pain is due to increased luminal pressure from obstructed gallbladder neck or cystic duct due to stone or sludge 
  • Clinical:
    • RUQ, epigastric, substernal pain
    • Pain can radiate to back or right shoulder 
    • Pain is constant despite the name of colic 
    • Associated Nausea, Vomiting & Diarrhea
    • Gradually resolve after < 6 hours so by the time we them, patient may be pain free; peak pain severity is about 1 hour 
  • Why are Gallstones so Important: because of the complications they cause!
      • Cholecystitis
      • Choledocholithiasis 
      • Acute Cholangitis
      • Gallstone Pancreatitis
      • Gallstone Ileus
      • Mirizzi Syndrome: Stone impocated in neck or distal cytic duct that is so large that it compresses the common hepatic duct. 


  • Diagnosis:
    • Transabdominal Ultrasound: sensitivity ~ 95% for detecting stones > 3 mm; sensitivty drops to ~60 if gallstones are < 3 mm 
    • If Transabdominal Ultrasound is negative:
      • Repeat US in 1 week if high suspicion negative US (there may be a small stone
      • Endoscopic US by GI is another option (indicated when pretest probability is high)
  • Management:
    • Analgesia: can start with an NSAID such as Toradol 
    • Cholecystectomy: will be needed eventually so give patient outpatient surgical referral 


  • Prognostication: Tokyo Guidelines
    • Provides diagnostic criteria and severity grading for Acute Cholecystitis 
    • Hypotensive, AMS, WBC > 18k, Platelets < 100k, INR > 1.5, Cr > 2 = SICK PATIENT 
  • Management:
    • Analgesia, Resuscitation as needed
    • Antibiotics: 
      • Zosyn
      • Cefepime & Flagyl
      • Ertapenem
    • Consult: Surgery


  • Primary: formation of stones within Common Bile Duct (CBD)
    • Etiology: Biliary Stasis, Cystic Fibrosis
  • Secondary: passage of stone from Gallbladder into CBD

Acute Cholangitis