Biliary Colic vs Cholecystitis vs Cholangitis

Introduction
Biliary colic, cholecystitis, and acute cholangitis are common conditions that affect the biliary system, usually due to gallstones. These conditions represent a spectrum of biliary pathology with overlapping features, making differentiating them challenging. 
Cholecystitis and acute cholangitis, in particular, often require immediate medical attention, so identifying these based on their associated signs and symptoms is important.
Want discounted access to all Geeky Medics products, including our medicine flashcard collection? Check out our bundles to save money and supercharge your learning 🔥
Biliary colic
Biliary colic is the most common complication of gallstones. It refers to the acute, painful spasm of the gallbladder wall due to a gallstone temporarily blocking the neck of the gallbladder, cystic duct or common bile duct.1,2
With the flow of bile being obstructed, the pressure increases, so the gallbladder contracts to try and push the bile past the gallstone, further increasing the pressure against the gallbladder wall, resulting in visceral pain.3
Biliary colic tends to be preceded by a fatty meal.2
Clinical features
The pain associated with biliary colic tends to be a sudden onset, severe, colicky pain, usually in the right upper quadrant.
This pain may also radiate to the epigastric region, right shoulder, and interscapular region. Patients are usually otherwise systemically well but may display voluntary guarding.4,5
Investigations
Blood tests are usually normal as biliary colic does not usually result in changes in inflammatory markers or liver function tests.6
The gold standard investigation to visualise gallstones is an abdominal ultrasound.
Management
For patients with milder symptoms, simple analgesia and lifestyle changes can aid with symptom management, including weight loss, a low-fat diet, and avoiding triggers such as fatty meals.1
However, after an episode of biliary colic, most patients will experience further episodes, with an estimated 60% of patients experiencing recurrent pain within two years of the initial attack.3
Therefore, for patients suffering from recurrent attacks, a referral for an elective laparoscopic cholecystectomy should be made.1

Biliary colic – key features

May have risk factors for gallstones
Episodes of sudden onset, severe, colicky RUQ pain, may be provoked by meals
Systemically well patient (not an inflammatory condition)
Normal inflammatory markers (WCC, CRP) and liver function tests
Abdominal ultrasound best investigation
May require elective cholecystectomy

Acute cholecystitis
Acute cholecystitis refers to the acute inflammation of the gallbladder, with 90% of cases being secondary to gallstones.7
Acute cholecystitis is usually secondary to a gallstone being impacted in the neck of the gallbladder or cystic duct, impeding bile flow.8
Clinical features
Patients with acute cholecystitis report much more constant pain in the right upper quadrant, which may radiate to the epigastrium and/or the right shoulder and interscapular region.8 The pain is often worse on deep inspiration.9
Murphy’s test is often positive in acute cholecystitis. This can be elicited by palpating the RUQ whilst asking the patient to inspire. Patients often halt their inspiration (inspiratory catch) due to pain.10
Unlike with biliary colic, patients tend to be systemically unwell and may have a fever, nausea and vomiting.8
Investigations
In acute cholecystitis, inflammatory markers (such as the white cell count and CRP) are usually raised.
Liver function tests may be normal or show a raised bilirubin, ALP, ALT, and gamma-GT.11
Like biliary colic, ultrasound is the gold standard for diagnosis, which helps to detect any signs of gallstones and associated gallbladder wall inflammation. However, when this is not available, or when sepsis is suspected, a CT scan with contrast or MRI should be requested, which can help to rule out other intra-abdominal pathologies, gangrenous cholecystitis and any perforations.11
Management
As most patients are usually systemically unwell, acute cholecystitis normally requires hospital admission for oral or IV antibiotics, depending on what the patient can tolerate.12
Although symptoms can improve with antibiotics, most patients will undertake a laparoscopic cholecystectomy within seven days of diagnosis.13
For patients who are critically unwell or unable to tolerate general anaesthesia (e.g. due to frailty or significant comorbidity), a percutaneous cholecystostomy is an alternative option.11

Acute cholecystitis – key features

May have risk factors for gallstones
Constant right upper quadrant pain, which may radiate
May be systemically unwell with associated symptoms (e.g. nausea/vomiting)
Raised inflammatory markers (CRP/WCC) – this is an inflammatory condition
Liver function tests may be normal or abnormal
Abdominal ultrasound best investigation
Require antibiotics and cholecystectomy

Acute cholangitis
Acute cholangitis, or ascending cholangitis, refers to an acute bacterial infection of the biliary tree and is one of the most serious complication of gallstones.14
Acute cholangitis occurs when there is an obstruction of the biliary tree, which is usually secondary to an impacted gallstone, strictures or as a complication of endoscopic retrograde cholangiopancreatography (ERCP).14
Bile stasis provides bacteria (usually gram-negative and anaerobic bacteria) with the ideal conditions to multiply. As time progresses, this infection tends to ascend proximally towards the liver.15
Clinical features
Ascending cholangitis should be suspected in patients who are jaundiced and who appear systemically unwell.
Patients may present with pale stools and dark urine and may also present with concurrent sepsis.15 
A triad of symptoms, called Charcot’s triad, is often seen:16

Right upper quadrant pain
Jaundice
Fever

Investigations
Blood tests will typically show an elevated white cell count and raised CRP.
As many patients are septic, patients may also have thrombocytopenia, coagulopathies and a raised lactate.
Liver function tests will generally show an obstructive jaundice picture (raised ALP and bilirubin).17
Gamma-GT will sometimes be mildly raised, and ALT and AST may also be mildly elevated.
Ultrasound is often used as a first line to look for a dilated bile duct. If this is negative, an abdominal CT with IV contrast should be requested.
The gold standard for diagnosing ascending cholangitis is with ERCP. However, as this procedure is invasive, magnetic resonance cholangiopancreatography (MRCP) is often preferred.17
Management
Many patients will be septic, so prompt administration of broad-spectrum IV antibiotics and IV fluids is essential, as well as any correction of any electrolyte or coagulation disturbances.
ERCP is diagnostic and therapeutic and is used to decompress the biliary tree urgently.
Percutaneous trans-hepatic cholangiography (PTC) is the second line for patients where this is unsuitable or if ERCP has been unsuccessful.17

Acute cholangitis – key features

May have risk factors for gallstones or recently had ERCP
Constant right upper quadrant pain, which may radiate
Usually systemically unwell with associated symptoms (e.g. nausea/vomiting), may be critically unwell and septic
Raised inflammatory markers (CRP/WCC) – this is an inflammatory condition
Liver function tests abnormal – obstructive jaundice
Abdominal ultrasound initial investigation
Requires antibiotics and ERCP

Summary table
Table 1. Overview of biliary colic, cholecystitis and acute cholangitis

 
Biliary colic
Cholecystitis
Acute cholangitis

Aetiology
Temporary blockage of the gallbladder neck, cystic duct or common bile duct by gallstones
Inflammation of the gallbladder, usually secondary to gallstones
Acute bacterial infection of the biliary tree secondary to bile stasis

Clinical features

Sudden onset, severe, dull, colicky pain in the RUQ
May radiate to the epigastric region, right shoulder and interscapular region
Systemically well

Constant RUQ pain
May radiate to the epigastrium and/or right shoulder and interscapular region
Pain is worse on deep inspiration
Murphy’s positive
Usually systemically unwell

Charcot’s triad of RUQ pain, fever and jaundice
Systemically very unwell (fever, hypotension, tachycardia, tachypnoea, rigours)

Investigations

Inflammatory markers and LFTs are usually normal
Abdominal ultrasound to confirm gallstones

↑ WCC/CRP
Liver function tests may be normal or may show a raised bilirubin, ALP, ALT and Gamma-GT
Ultrasound or CT/MRI

↑ WCC/CRP
↑ ALP and bilirubin
Gamma-GT, AST and ALT may also be mildly ↑
Ultrasound or CT, ERCP (gold-standard) or MRCP

Management

Analgesia, lifestyle advice and elective laparoscopic cholecystectomy

Consider hospital admission for oral/IV antibiotics
Laparoscopic cholecystectomy

Sepsis six, broad-spectrum antibiotics
ERCP

References

NICE CKS. Gallstones. Published in 2019. Available from: [LINK]
Sigmon DF, Dayal N, Meseeha M. Biliary Colic [Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2020. Available from: [LINK]
Callery, M. P., Beard, R. E., & Stewart, L. (2017). Cholecystolithiasis and stones in the common bile duct: Which approach and when?. In Blumgart’s Surgery of the Liver, Biliary Tract and Pancreas, 2-Volume Set (pp. 623-632). Elsevier.

NHS Choices. Gallstones. Published in 2017. Available from: [LINK]

Miss Laura Jayne Watson. Gallstones. Published in 2023. Available from: [LINK]

Paterson-Brown, S. (Ed.). (2013). Core Topics in General & Emergency Surgery E-Book: Companion to Specialist Surgical Practice. Elsevier Health Sciences.

Indar, A. A., & Beckingham, I. J. (2002). Acute cholecystitis. BMJ, 325(7365), 639-643.

NICE CKS. Cholecystitis. Published in 2021. Available from: [LINK]
NHS Choices. Acute cholecystitis. Published in 2019. Available from: [LINK]
Musana K, Yale SH. John Benjamin Murphy (1857 – 1916). Clinical Medicine and Research [Internet]. 2005 May 1;3(2):110–2. Available from: [LINK]
BMJ Best Practice. Acute cholecystitis – Investigations. Published in 2022. Available from: [LINK]
Royal College of Surgeons. Commissioning guide: Gallstone disease. 2016.
NICE. Gallstone disease: diagnosis and management. Published in 2014. Available from: [LINK]
Ahmed M. Acute cholangitis – an update. World Journal of Gastrointestinal Pathophysiology. 2018 Feb 15;9(1):1–7.
Virgile J, Marathi R. Cholangitis [Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2020. Available from: [LINK]
Tan SY, Chong CF, Chong VH. Charcot’s triad. QJM: An International Journal of Medicine [Internet]. 2020 Feb 3;113(6):436–6. Available from: [LINK]
BMJ Best Practice. Acute Cholangitis – Symptoms, Diagnosis And Treatment. Available from: [LINK]