Clinical Features

History: Gallstones usually remain asymptomatic throughout the patient’s life.
The most common presenting symptom is intermittent pain below the right ribcage; pain might radiate to the back.

• Nausea, with or without vomiting, might be present.

• Certain foods, especially those with high fat content, can provoke symptoms. The patient might experience episodes of acute abdominal pain, called biliary colic.
  Physical: Physical examination frequently is normal.

• Discomfort might be elicited on deep palpation of the right upper quadrant of the abdomen.

• Murphy sign (pain on palpation of the right upper quadrant when the patient inhales) might indicate acute cholecystitis. Other signs of cholecystitis include fever and tachycardia.

• Physical exam might indicate complications of cholelithiasis.
  

  • Passage of gallstones from the gallbladder into the common bile duct can result in a complete or partial obstruction of the common bile duct. Frequently, this manifests as jaundice. In all races, jaundice is detected most reliably by examination of the sclera in natural for yellow discoloration.

  • Pancreatitis, another complication of gallstone disease, presents with more diffuse abdominal pain, including pain in the epigastrium and left upper quadrant of the abdomen.

  • Severe hemorrhagic pancreatitis occurs in 15% patients and carries a high mortality because of multisystem organ failure. In a few patients, the hemorrhagic pancreatic process and retroperitoneal bleeding induce discoloration around the umbilicus (Cullen sign) or the flank (Grey-Turner sign).

  • Charcot triad (right upper quadrant pain, fever, and jaundice) is associated with common bile duct obstruction and cholangitis. Additional symptoms, such as alterations in the mental status and hypotension, indicate Raynaud pentad, a harbinger of worsening, ascending cholangitis.

  
  

Mortality and morbidity are related directly to the complications of the disease and its surgical treatment. Approximately 10% patients with gallstones have common bile duct stones as well. The natural history of common

bile duct stones is not completely known. Gallstones can cause obstruction of the common bile duct, causing jaundice. Cholangitis, a potentially life-threatening infection, can follow biliary obstruction. Obstruction of the neck of the gallbladder causes

bile stasis, which can lead to inflammation and edema of the gallbladder wall. Sequelae of this condition include acute cholecystitis secondary to compromised lymphatic, venous, and, ultimately, arterial supply to the gallbladder. The latter can lead to gangrene or abscess formation.