About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Gallstones affect ~15% of UK adults; most are asymptomatic and do not require treatment
- Biliary colic: severe colicky RUQ/epigastric pain lasting 30 min–6 h, often post-prandial (especially fatty food), self-resolving
- First-line investigation: abdominal USS (>95% sensitive for gallbladder stones)
- Symptomatic gallstones: laparoscopic cholecystectomy (elective, ideally day-case) — definitive treatment
- Asymptomatic gallstones found incidentally: reassurance only, no treatment needed (NICE CG188)
Overview
Gallstones (cholelithiasis) are solid concretions forming within the gallbladder from precipitation of bile components. Approximately 80% are cholesterol stones (associated with obesity, oestrogen, rapid weight loss) and 20% are pigment stones (associated with haemolytic anaemias, liver cirrhosis). Biliary colic occurs when a gallstone transiently obstructs the cystic duct, causing visceral pain that typically resolves when the stone disimpacts. Persistent obstruction leads to complications: acute cholecystitis, choledocholithiasis (CBD stones), ascending cholangitis, and gallstone pancreatitis.
Epidemiology
Approximately 10–15% of the UK adult population have gallstones. Most (>80%) are asymptomatic. Risk factors include female sex, age >40, obesity, rapid weight loss, multiparity, family history, and certain ethnic groups. The classic "5 Fs" (Fat, Female, Fertile, Forty, Fair) are a rough clinical mnemonic. Approximately 50,000 cholecystectomies are performed annually in England. Once symptomatic, there is a 1–3% annual risk of complications.
Clinical Features
Symptoms
Severe colicky RUQ or epigastric pain lasting 30 min to 6 hours
Pain often precipitated by fatty meals
Pain may radiate to right shoulder or interscapular region (referred diaphragmatic irritation)
Nausea and vomiting during episodes
Completely well between attacks
Fever and persistent RUQ pain >6 hours (suggests cholecystitis — not simple biliary colic)
Jaundice (suggests CBD stone)
Signs
RUQ tenderness during episode
Usually normal examination between episodes
Positive Murphy sign (pain and inspiratory arrest on palpation of RUQ — suggests cholecystitis, not simple colic)
Jaundice and dark urine (CBD obstruction)
Fever and rigors (cholangitis)
Investigations
First-line
Abdominal ultrasoundFirst-line investigation — >95% sensitivity for gallbladder stones. Look for stones, gallbladder wall thickening, pericholecystic fluid, CBD dilatation
LFTsBilirubin, ALP, GGT raised if CBD obstruction. ALT/AST may be raised in biliary pathology. Normal in uncomplicated biliary colic
FBC, CRPRaised WCC and CRP suggest cholecystitis or cholangitis, not simple biliary colic
Second-line
MRCPIf CBD stones suspected (dilated CBD, raised bilirubin/ALP) but USS inconclusive — non-invasive assessment of biliary tree
Endoscopic ultrasound (EUS)If MRCP equivocal and high clinical suspicion of CBD stone
Specialist
ERCPTherapeutic — for removal of confirmed CBD stones (sphincterotomy + balloon extraction). Not a first-line diagnostic test
Intraoperative cholangiogramAt time of cholecystectomy to assess for CBD stones if LFTs abnormal or CBD dilated
Management
NICE CG188 (Gallstone disease), 20141
Asymptomatic gallstones
- Reassure — no treatment required
- Advise to seek medical attention if symptoms develop
2
Biliary colic — acute episode
- Analgesia: diclofenac 75 mg IM (first-line for biliary colic — superior to opioids in RCTs)
- Antiemetic: prochlorperazine or ondansetron
- Dietary advice: avoid fatty foods to reduce recurrence
3
Definitive treatment
- Laparoscopic cholecystectomy: offered to all patients with symptomatic gallstones
- Day-case procedure where possible (NICE CG188)
- If CBD stones present: ERCP ± sphincterotomy before or at time of cholecystectomy
- Avoid ursodeoxycholic acid for gallstone dissolution — low efficacy and high recurrence
Complications
- Acute cholecystitis: Persistent cystic duct obstruction → gallbladder inflammation ± infection
- Choledocholithiasis: Stone in CBD → obstructive jaundice
- Ascending cholangitis: CBD obstruction + infection → Charcot triad (pain, jaundice, fever) — life-threatening
- Gallstone pancreatitis: Stone impacted at ampulla of Vater → pancreatic duct obstruction
- Gallbladder empyema/perforation: Pus accumulation or rupture of acutely inflamed gallbladder
- Mirizzi syndrome: Stone impacted in Hartmann pouch compressing common hepatic duct
- Gallstone ileus: Large stone eroding through into duodenum → small bowel obstruction (rare)
UKMLA Exam Tips
- 1Biliary colic lasts 30 min–6 h. If pain persists beyond 6 hours with fever → think cholecystitis
- 2Diclofenac IM is the first-line analgesic for biliary colic (NICE CG188) — better than opioids
- 3Asymptomatic gallstones found incidentally: NO treatment, reassure (NICE CG188)
- 4USS is first-line but misses CBD stones in ~50% — MRCP if LFTs deranged or CBD dilated
- 5Murphy sign = pain on RUQ palpation with inspiratory arrest — positive in cholecystitis, NOT simple biliary colic
- 6Mirizzi syndrome = stone in cystic duct/Hartmann pouch compressing common hepatic duct → obstructive jaundice
practicetest your knowledge on gallstonesApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — gastroenterology and beyond.
open q-bank