A lot of the western world have stones in their gallbladders (cholelithiasis) but for the most part they just grumble along with no trouble at all.

1. Cholelithiasis – Gallstones just hanging out, not causing any problems
2. Biliary colic – happens after a fatty meal, the GB contracts and pushes stones into the cystic duct but when the duct relaxes the stone rolls back into the GB. The pain is entirely visceral and generally lasts <6h. There should be no fever or chills.
3. Cholecystitis – inflammation of the GB. It’s biliary colic that just doesn’t go away. The pain lasts longer than 6h and is usually associated with nausea/vomiting, fever and right upper quadrant pain.
4. Choledocholithiasis – gallstones in the common bile duct. Usually secondary to cholelithiasis, but can be a primary stone in cases of bile stasis or recurrent infection of the biliary tree. Usually have abnormalities in liver enzymes and pain but no fever.
   The 2 major complications are 1) Cholangitis and 2) Acute pancreatitis.
5. Cholangitis – infection/inflammation of the biliary tree (infected bile or gallstone), secondary to an impacted stone or stricture(s).
   Do an ultrasound. Start antibiotics (common bugs are a mix of gram +/- and anaerobes = E. coli, enterococcus, bactericides). Ciprofloxacin or a combination of ampicillin, ceftazimide and metronidazole.
   Make sure that the person receives some fluid resuscitation to help with the hypoperfusion
   Charcot’s triad: fever, RUQ pain, jaundice
   Reynold’s pentad: hypoperfusion, decreased level of consciousness (SHOCK!!!)
   DDx
   • Biliary leaks
   • Liver abscess
   • Infected choledochal cysts
   • Cholecystitis
   • Mirizzi syndrome
   • Right lower lobe pneumonia/empyema

Lab values