Extrahepatic bile-duct stones (choledocholithiasis) are most frequently cholesterol calculi that have migrated from the gallbladder, or primary pigment stones that form de novo within the common bile duct. Symptoms depend on the degree of obstruction, the presence of infection, and the duration of bile stasis.
- Biliary colic
Epigastric or right-upper-quadrain pain begins 30–60 min after a fatty meal, builds steadily for ≥30 min, may last several hours, and radiates to the right scapula or inter-scapular region. Movement does not relieve the discomfort, and antacids are ineffective. - Nausea and vomiting
Gastric stasis and vagal reflexes produce repeated retching that may transiently lessen pain. - Fluctuating jaundice
Intermittent occlusion of the common bile duct elevates conjugated bilirubin, producing scleral icterus, dark urine, and clay-coloured stools that wax and wane as stones impinge or disimpact. - Cholangitis
Complete obstruction plus bacterial contamination produces Charcot triad: spiking fever with rigors, persistent RUQ pain, and deepening jaundice. Suppurative forms add hypotension and mental confusion (Reynolds pentad), indicating pus under pressure within an obstructed ductal system. - Acute pancreatitis
Impaction at the ampulla obstructs both bile and pancreatic flow, leading to mid-epigastric pain radiating to the back, intractable vomiting, and elevated serum amylase/lipase. - Abdominal tenderness and guarding
Deep palpation elicits localized guarding; inspiratory arrest during RUQ palpation (Murphy sign) may be positive if concomitant acute cholecystitis is present. - Systemic response
Tachycardia, low-grade pyrexia, and elevated C-reactive protein accompany active obstruction; leukocytosis is common during infective episodes.
| Symptom / Sign | Typical Presentation |
|---|---|
| Biliary colic | Post-prandial RUQ/epigastric pain ≥30 min, radiates to scapula |
| Nausea/vomiting | Repeated, may transiently relieve pain |
| Jaundice | Fluctuating, dark urine, pale stools |
| Cholangitis | Fever + RUQ pain + jaundice (Charcot triad) |
| Acute pancreatitis | Epigastric pain to back, intractable vomiting |
| Tenderness/guarding | Localized RUQ, positive Murphy sign possible |
| Systemic | Tachycardia, low-grade fever, leukocytosis |