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Main Clinical Manifestations of Bile-Duct Stones

Choledocholithiasis denotes the presence of calculi within the extra- or intrahepatic bile ducts. Symptoms arise when a stone obstructs flow, triggers inflammation, or provokes infection. The presentation ranges from silent imaging findings to life-threatening sepsis.

  1. Biliary colic
    Epigastric or right-upper-quadrant pain begins 30–60 min post-prandially, peaks for ≥30 min, and radiates to the inter-scapular region or right shoulder. Movement does not relieve the discomfort, and analgesics are often required.
  2. Nausea and vomiting
    Gastric stasis and vagal reflexes produce repeated retching that may transiently lessen pain.
  3. Fluctuating jaundice
    Intermittent elevation of conjugated bilirubin produces scleral icterus, dark urine, and clay-coloured stools that wax and wane as stones impact or disimpact.
  4. Cholangitis
    Complete obstruction plus bacterial contamination yields Charcot triad: spiking fever with rigors, constant RUQ pain, and deepening jaundice. Suppurative forms add hypotension and mental confusion (Reynolds pentad), indicating pus under pressure.
  5. Acute pancreatitis
    Impaction at the ampulla obstructs both bile and pancreatic flow, leading to epigastric pain radiating to the back, intractable vomiting, and elevated serum amylase/lipase.
  6. Tender hepatomegaly
    The liver edge is smooth, hot and exquisitely tender; inspiratory arrest on palpation (Murphy sign) is frequent when concomitant acute cholecystitis is present.
  7. Laboratory cholestasis
    Serum alkaline phosphatase and γ-glutamyl transferase rise early; total bilirubin climbs steadily as obstruction persists.
Symptom / SignTypical Presentation
Biliary colicPost-prandial RUQ/epigastric pain ≥30 min
Nausea/vomitingRepeated, may transiently relieve pain
JaundiceFluctuating, dark urine, pale stools
CholangitisFever + RUQ pain + jaundice (Charcot triad)
Acute pancreatitisEpigastric pain to back, ↑ amylase/lipase
Tender hepatomegalyHot, painful edge, positive Murphy sign
Laboratory↑ ALP, ↑ GGT, ↑ total bilirubin

Related articles：

  1. Main Clinical Manifestations of Extrahepatic Bile-Duct Stones
  2. How is bile-duct stone disease treated?
  3. Main Clinical Manifestations of Cholangitis
  4. Main Clinical Manifestations of Hepatic Hydatid Disease
  5. Main Clinical Manifestations of Biliary Tract Diseases
  6. Main Clinical Manifestations of Chronic Cholecystitis

Main Clinical Manifestations of Cholangitis

Cholangitis denotes acute bacterial infection within the biliary tree, most commonly precipitated by obstruction from stones, strictures, or neoplasia. The spectrum ranges from mild ductal inflammation to life-threatening sepsis. Recognition of its cardinal features guides urgent biliary decompression and antimicrobial therapy.

Complication warnings
Persistent fever despite antibiotics, uncontrolled hypotension, or new-onset renal dysfunction suggests progressive sepsis and requires urgent endoscopic or percutaneous biliary drainage.

Charcot triad
Intermittent high spiking fever with rigors, constant right-upper-quadrant pain, and conjugated hyper-bilirubinaemia constitute the classical presentation seen in ~70 % of patients with incomplete or partial obstruction.

Reynolds pentad
Addition of hypotension (systolic BP < 90 mmHg) and altered mental status marks suppurative cholangitis with septic shock; this combination mandates emergency ductal drainage.

Jaundice and pruritus
Scleral icterus, dark urine, and clay-coloured stools reflect impaired bile flow; intractable pruritus results from cutaneous deposition of bile salts.

Tender hepatomegaly
The liver edge is hot, exquisitely painful to percussion, and may show a soft bulge over the obstructed segment; inspiratory arrest on palpation (Murphy sign) is frequent when concomitant acute cholecystitis is present.

Gastro-intestinal upset
Anorexia, nausea, and intermittent vomiting are common; large duct obstruction produces early satiety and eructation.

Systemic toxicity
Tachycardia > 100 beats min⁻¹, prolonged capillary refill, elevated lactate, and leukocytosis with left shift indicate bacteraemia and impending septic shock.

Laboratory cholestasis
Serum alkaline phosphatase and γ-glutamyl transferase rise early; total bilirubin climbs steadily as obstruction persists; blood cultures frequently yield enteric Gram-negative bacilli.

Symptom / SignTypical Presentation
Charcot triadFever + RUQ pain + jaundice
Reynolds pentadAbove + hypotension + confusion
JaundiceConjugated, dark urine, pale stools
Tender hepatomegalyHot, painful edge, positive Murphy
GI upsetNausea, vomiting, early satiety
Systemic toxicityTachycardia, leukocytosis, elevated lactate
Laboratory↑ ALP, ↑ GGT, ↑ bilirubin, positive blood cultures
Alarm signsRefractory fever, shock, renal dysfunction

Related articles：

  1. Main Clinical Manifestations of Bile-Duct Stones
  2. Main Clinical Manifestations of Hepatic Hydatid Disease
  3. Main Clinical Manifestations of Extrahepatic Bile-Duct Stones
  4. Main Clinical Manifestations of Biliary Tract Diseases
  5. Main Clinical Manifestations of Congenital Biliary Malformations
  6. Main Clinical Manifestations of Chronic Cholecystitis