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Biliary Colic and Cholecystitis ConcernAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

569 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Abdominal Distension Abdominal Pain, Undifferentiated Acute Abdominal Pain (general)Suspected Incarcerated Or Strangulated Hernia Pancreatitis Concern Biliary Colic And Cholecystitis Concern Appendicitis Concern Diverticulitis Concern Rectal Pain And Anorectal Complaints Dysphagia And Food Bolus Impaction Foreign Body Ingestion Refractory Vomiting And Recurrent Vomiting Syndromes Cannabis Associated Hyperemesis Upper Gastrointestinal Bleeding Symptoms (melena)Lower Gastrointestinal Bleeding And Hematochezia Constipation And Obstipation Diarrhea Acute Hepatitis And Jaundice Concern Right Upper Quadrant Pain Epigastric Pain Left Upper Quadrant Pain Right Lower Quadrant Pain Left Lower Quadrant Pain Suprapubic Pain

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx58

Presenting symptoms

›Symptom profile

›Right upper quadrant pain

›Epigastric pain

›Postprandial pain

›Pain after fatty meals

›Nausea

›Vomiting

›Anorexia

›Subjective fever

›Jaundice

›Dark urine

›Pale stools

›Pruritus

›Prior similar episodes

›Baseline functional status change

OPQRST

›OPQRST framework

›Onset

›Time of onset

›Sudden onset

›Gradual onset

›First episode

›Recurrent episodes

›Provocation and palliation

›Triggered by meals

›Triggered by fatty foods

›Worse with movement

02Alarm Features/alarm36

Immediate escalation triggers

›High risk features

›Hemodynamic instability

›Hypotension

›Shock physiology

›Altered mental status

›Confusion

›Lethargy

›Sepsis features

›Fever with rigors

›Tachycardia with toxicity

›Hypothermia

›Peritonitis

›Rebound tenderness

›Guarding

›Suspected ascending cholangitis

›Fever

›Jaundice

›Right upper quadrant pain

›Hypotension

›Altered mental status

›Suspected gallbladder perforation

›Diffuse abdominal pain

›Peritoneal signs

›Suspected pancreatitis with organ dysfunction

›Persistent hypotension

›Hypoxemia

›Suspicion of myocardial ischemia mimic

03Medications/meds35

Current and recent agents

›Medication reconciliation

›Anticoagulants

›Warfarin

›Direct oral anticoagulants

›Antiplatelets

›Aspirin

›P2Y12 inhibitors

›Diabetes therapies

›GLP 1 receptor agonists

›SGLT2 inhibitors

›Opioids

›Baseline opioid use

›Recent dose escalation

›NSAIDs

›Recent use

›Contraindication history

›Antibiotics

›Recent courses

›Allergy history

›Hormonal therapy

›Estrogen exposure

›Pregnancy related medications

›Supplements and herbals

›Weight loss supplements

›Hepatotoxic supplements

Medication interactions and contraindications

›Therapy limitations

04Diet/diet9

Recent intake patterns

›Dietary exposures

›High fat meals

›Recent fasting

›Rapid weight loss dieting

›Low fiber intake

›Dehydration pattern

›Poor oral intake

›Alcohol exposure

›Caffeine and energy drinks

05Review of Systems/ros23

Gastrointestinal and hepatobiliary

›ROS cluster

›Nausea

›Vomiting

›Bloating

›Diarrhea

›Constipation

›Hematemesis

›Melena

›Hematochezia

›Dyspepsia

›Jaundice

›Pruritus

›Dark urine

›Pale stools

Cardiopulmonary and systemic

›ROS cluster

›Chest pain

›Dyspnea

›Palpitations

›Syncope

›Fever

›Chills

›Weight loss

›Night sweats

06Collateral History and Family History/chafh7

Family and collateral

›Collateral and family risks

›Collateral source reliability

›Family history gallstones

›Family history hemolytic disorders

›Family history early cardiovascular disease

›Household sick contacts

›Social support reliability for discharge

07Risk Factors/rf24

Patient specific risks for gallstone disease and complications

›Risk profile

›Female sex

›Age older than 40

›Pregnancy

›Postpartum state

›Obesity

›Rapid weight loss

›Diabetes mellitus (E11.9)

›Hemolytic disease

›Sickle cell disease (D57.1)

›Hereditary spherocytosis (D58.0)

›Cirrhosis (K74.60)

›Total parenteral nutrition exposure

›Prior biliary colic

›Prior gallstone pancreatitis (K85.1)

›Prior choledocholithiasis (K80.50)

›Immunocompromised state

›Older adult frailty

Exposure and procedural risks

›Additional risks

›Recent ERCP

›Recent abdominal surgery

›Recent trauma

›Travel related infection risk

›Foodborne illness exposure

08Differential Diagnosis/ddx70

Life threatening

›High risk differentials

›Ascending cholangitis (K83.09)

›Fever with jaundice

›Hypotension

›Altered mental status

›Gallstone pancreatitis (K85.1)

›Epigastric pain radiating to back

›Lipase elevation

›Organ dysfunction

›Perforated viscus (K63.1)

›Sudden severe pain

›Peritonitis

›Abdominal aortic aneurysm rupture (I71.3)

›Back pain

›Hypotension

›Pulsatile mass

›Acute coronary syndrome (I21.9)

›Epigastric pain mimic

›Diaphoresis

›Exertional component

›Mesenteric ischemia (K55.9)

›Pain out of proportion

›Lactate elevation

›Hepatic abscess (K75.0)

›Fever

›Right upper quadrant tenderness

›Sepsis of unclear source (A41.9)

09Past Medical History/pmh25

Relevant history and procedures

›Key background

›Known cholelithiasis

›Prior imaging results

›Prior surgical consultation

›Prior cholecystitis

›Complications

›Antibiotic history

›Prior pancreatitis

›Etiology

›Severity

›Prior ERCP

›Sphincterotomy

›Stents

›Prior abdominal surgeries

›Gastric bypass

›Hepatobiliary surgery

›Chronic liver disease

›Cirrhosis

›Portal hypertension

›Cardiac disease

›Coronary artery disease (I25.10)

›Heart failure (I50.9)

›Pregnancy status

›Gestational age

›Obstetric complications

10Physical Exam/exam32

General and vitals

›General assessment

›Ill appearance

›Toxic appearance

›Diaphoresis

›Hydration status

›Vital sign pattern

›Fever

›Tachycardia

›Hypotension

Abdominal and hepatobiliary

›Abdominal exam cluster

›Right upper quadrant tenderness

›Epigastric tenderness

›Murphy sign

›Guarding

›Rebound tenderness

›Distension

›Hepatomegaly

›Palpable gallbladder

›Bowel sounds abnormality

Skin cardiopulmonary and neuro

›Focused exam cluster

›Scleral icterus

›Jaundice

›Excoriations from pruritus

›Chest exam

›Right lower lobe crackles

11Lab Studies/labs32

Core laboratory evaluation

›Baseline labs for biliary pathology

›CBC

›Leukocytosis support for cholecystitis

›Hemolysis clues if pigment stones suspected

›Electrolytes and renal function

›Dehydration assessment

›Renal dosing prompts

›Liver enzymes and bilirubin

›AST and ALT

›Alkaline phosphatase

›GGT

›Total bilirubin

›Direct bilirubin

›Lipase

›Pancreatitis support

›Mild elevation nonspecific

›Lactate

›Sepsis physiology

›Mesenteric ischemia concern

›CRP

›Inflammatory severity support

›Trend utility

›Blood cultures

›Fever with suspected cholangitis

›Before antibiotics when feasible

Pregnancy and metabolic modifiers

›Special population labs

12Imaging/img52

Scoring Systems

›Severity and risk tools

›Tokyo Guidelines acute cholecystitis severity

›Grade I mild

›Grade II moderate

›Grade III severe with organ dysfunction

›ASGE risk stratification for choledocholithiasis

›High probability features

›Intermediate probability features

›Low probability features

›Limitations

›Local protocol dependent operational definitions

›Does not replace clinical judgment in shock

MRI

›MRI and MRCP use cases

›MRCP for suspected choledocholithiasis

›Cholestatic lab pattern

›Ductal dilation on ultrasound

›Pregnancy preferred cross sectional imaging when available

›Avoid gadolinium unless essential

›Local protocol dependent

›Interpretation pearls

›Common bile duct stone visualization

›Stricture and malignancy differentiation prompts

›CT abdomen pelvis role

›Complications suspected

›Perforation

13Special Tests/spec14

Functional and adjunct diagnostics

›Additional tests when ultrasound nondiagnostic

›HIDA scan

›Nonvisualization consistent with acute cholecystitis

›Delayed filling supportive of chronic cholecystitis

›Endoscopic ultrasound

›Intermediate risk choledocholithiasis

›Small duct stones detection

›ERCP diagnostic and therapeutic

›High probability choledocholithiasis

›Ascending cholangitis urgent decompression

Bedside maneuvers and reassessment

›Serial bedside reassessment

›Pain trajectory after analgesia

›Evolving peritoneal signs

›Worsening jaundice or mental status change

14ECG/ecg10

When epigastric pain may be cardiac

›ECG indications

›Epigastric pain with diaphoresis

›Chest radiation

›Older age

›Diabetes mellitus

›Hypotension

›Abnormal vitals without clear abdominal source

›Serial ECG logic

›Persistent symptoms with initial nondiagnostic ECG

›Troponin pathway local protocol dependent

15Assessment/ax25

Working diagnoses and key distinctions

›Biliary colic (K80.20)

›Pain episodes less than 6 hours

›Afebrile

›Minimal tenderness between episodes

›Normal or near normal inflammatory markers

›Acute cholecystitis (K81.0)

›Persistent right upper quadrant pain more than 6 hours

›Fever or leukocytosis

›Murphy sign or localized peritonism

›Ultrasound inflammatory features

›Choledocholithiasis (K80.50)

›Jaundice

›Cholestatic lab pattern

›Ductal dilation

›Ascending cholangitis (K83.09)

›Systemic toxicity

›Fever with jaundice

›Hypotension or altered mental status

Complications to rule out

›Complication screen

›Gallstone pancreatitis (K85.1)

›Gallbladder perforation

›Emphysematous cholecystitis

›Hepatic abscess

›Sepsis

›Alternate life threat mimics

16Plan/plan62

First 5 minutes and stabilization

›Immediate workflow

›Triage to monitored setting if instability

›Continuous pulse oximetry

›Cardiac monitoring if systemic toxicity

›IV access

›Two large bore IV lines if hypotension or sepsis concern

›Single IV line if stable

›Fluids

›If hypotension then isotonic crystalloid bolus 500 mL to 1000 mL

›Reassess after each bolus for overload risk

›Analgesia initiation

›Ketorolac IV 15 mg

›Avoid ketorolac if renal impairment or GI bleed risk

›Hydromorphone IV 0.2 mg to 0.5 mg

›Repeat every 10 to 15 minutes to effect with monitoring

›Antiemetic

›Ondansetron IV 4 mg

›Repeat once if persistent

›Antibiotics only when infection suspected

›Early antibiotics if cholecystitis with systemic features

›Immediate antibiotics if cholangitis suspected

Differential Management

›!Cholecystitis→›!Choledocholithiasis and cholangitis→›Acute pancreatitis→

Diagnostic sequencing

›Workup pathway

17Disposition/dispo28

Admission and procedural pathways

›Level of care decision

›ICU criteria

›Persistent hypotension after fluids

›Vasopressor requirement

›Altered mental status from sepsis

›Lactate persistently elevated with shock physiology

›Inpatient admission criteria

›Acute cholecystitis with systemic signs

›Suspected choledocholithiasis requiring MRCP or ERCP

›Gallstone pancreatitis

›Uncontrolled pain or vomiting

›Inability to tolerate oral intake

›Significant comorbidity or frailty

›Observation pathway criteria

›Equivocal imaging with persistent symptoms

›Need for serial exams and repeat labs

›Discharge criteria

›Pain controlled on oral medications

›Tolerating oral fluids

›No fever

›No jaundice

›Reassuring labs and imaging

›Reliable follow up within 48 to 72 hours

Follow up timing

›Follow up plan

›Surgery referral for symptomatic cholelithiasis

›Timing within 1 to 2 weeks if recurrent biliary colic

18Discharge Instructions/di21

Copy discharge instructions

›Discharge text

›Diagnosis likely biliary colic from gallstones

›Return now for fever

›Return now for worsening or constant pain lasting more than 6 hours

›Return now for yellowing of eyes or skin

›Return now for dark urine or pale stools

›Return now for persistent vomiting or inability to keep fluids down

›Return now for fainting or severe weakness

›Diet for next 48 hours

›Low fat foods

›Small frequent meals

›Medications

›Acetaminophen as directed on label

›Avoid NSAIDs if kidney disease or stomach bleeding history

›Avoid alcohol while taking pain medicines

›Follow up

›Surgical consultation for gallbladder removal

›Primary care follow up within 1 week

›Safety

›Do not drive after opioid pain medication

›Seek care sooner if symptoms are changing quickly

19References/r6

Guidelines and evidence

›Evidence sources

›Tokyo Guidelines for management of acute cholecystitis and acute cholangitis 2018

›World Society of Emergency Surgery guidelines for acute calculous cholecystitis 2020

›American Society for Gastrointestinal Endoscopy guideline on choledocholithiasis risk stratification and ERCP indications 2019

›American College of Radiology Appropriateness Criteria right upper quadrant pain 2023

›Surviving Sepsis Campaign guidelines 2021

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Biliary Colic and Cholecystitis ConcernAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

569 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx58

Presenting symptoms

›Symptom profile

›Right upper quadrant pain

›Epigastric pain

›Postprandial pain

›Pain after fatty meals

›Nausea

›Vomiting

›Anorexia

›Subjective fever

›Jaundice

›Dark urine

›Pale stools

›Pruritus

›Prior similar episodes

›Baseline functional status change

OPQRST

›OPQRST framework

›Onset

›Time of onset

›Sudden onset

›Gradual onset

›First episode

›Recurrent episodes

›Provocation and palliation

›Triggered by meals

›Triggered by fatty foods

›Worse with movement

02Alarm Features/alarm36

Immediate escalation triggers

›High risk features

›Hemodynamic instability

›Hypotension

›Shock physiology

›Altered mental status

›Confusion

›Lethargy

›Sepsis features

›Fever with rigors

›Tachycardia with toxicity

›Hypothermia

›Peritonitis

›Rebound tenderness

›Guarding

›Suspected ascending cholangitis

›Fever

›Jaundice

›Right upper quadrant pain

›Hypotension

›Altered mental status

›Suspected gallbladder perforation

›Diffuse abdominal pain

›Peritoneal signs

›Suspected pancreatitis with organ dysfunction

›Persistent hypotension

›Hypoxemia

›Suspicion of myocardial ischemia mimic

03Medications/meds35

Current and recent agents

›Medication reconciliation

›Anticoagulants

›Warfarin

›Direct oral anticoagulants

›Antiplatelets

›Aspirin

›P2Y12 inhibitors

›Diabetes therapies

›GLP 1 receptor agonists

›SGLT2 inhibitors

›Opioids

›Baseline opioid use

›Recent dose escalation

›NSAIDs

›Recent use

›Contraindication history

›Antibiotics

›Recent courses

›Allergy history

›Hormonal therapy

›Estrogen exposure

›Pregnancy related medications

›Supplements and herbals

›Weight loss supplements

›Hepatotoxic supplements

Medication interactions and contraindications

›Therapy limitations

04Diet/diet9

Recent intake patterns

›Dietary exposures

›High fat meals

›Recent fasting

›Rapid weight loss dieting

›Low fiber intake

›Dehydration pattern

›Poor oral intake

›Alcohol exposure

›Caffeine and energy drinks

05Review of Systems/ros23

Gastrointestinal and hepatobiliary

›ROS cluster

›Nausea

›Vomiting

›Bloating

›Diarrhea

›Constipation

›Hematemesis

›Melena

›Hematochezia

›Dyspepsia

›Jaundice

›Pruritus

›Dark urine

›Pale stools

Cardiopulmonary and systemic

›ROS cluster

›Chest pain

›Dyspnea

›Palpitations

›Syncope

›Fever

›Chills

›Weight loss

›Night sweats

06Collateral History and Family History/chafh7

Family and collateral

›Collateral and family risks

›Collateral source reliability

›Family history gallstones

›Family history hemolytic disorders

›Family history early cardiovascular disease

›Household sick contacts

›Social support reliability for discharge

07Risk Factors/rf24

Patient specific risks for gallstone disease and complications

›Risk profile

›Female sex

›Age older than 40

›Pregnancy

›Postpartum state

›Obesity

›Rapid weight loss

›Diabetes mellitus (E11.9)

›Hemolytic disease

›Sickle cell disease (D57.1)

›Hereditary spherocytosis (D58.0)

›Cirrhosis (K74.60)

›Total parenteral nutrition exposure

›Prior biliary colic

›Prior gallstone pancreatitis (K85.1)

›Prior choledocholithiasis (K80.50)

›Immunocompromised state

›Older adult frailty

Exposure and procedural risks

›Additional risks

›Recent ERCP

›Recent abdominal surgery

›Recent trauma

›Travel related infection risk

›Foodborne illness exposure

08Differential Diagnosis/ddx70

Life threatening

›High risk differentials

›Ascending cholangitis (K83.09)

›Fever with jaundice

›Hypotension

›Altered mental status

›Gallstone pancreatitis (K85.1)

›Epigastric pain radiating to back

›Lipase elevation

›Organ dysfunction

›Perforated viscus (K63.1)

›Sudden severe pain

›Peritonitis

›Abdominal aortic aneurysm rupture (I71.3)

›Back pain

›Hypotension

›Pulsatile mass

›Acute coronary syndrome (I21.9)

›Epigastric pain mimic

›Diaphoresis

›Exertional component

›Mesenteric ischemia (K55.9)

›Pain out of proportion

›Lactate elevation

›Hepatic abscess (K75.0)

›Fever

›Right upper quadrant tenderness

›Sepsis of unclear source (A41.9)

09Past Medical History/pmh25

Relevant history and procedures

›Key background

›Known cholelithiasis

›Prior imaging results

›Prior surgical consultation

›Prior cholecystitis

›Complications

›Antibiotic history

›Prior pancreatitis

›Etiology

›Severity

›Prior ERCP

›Sphincterotomy

›Stents

›Prior abdominal surgeries

›Gastric bypass

›Hepatobiliary surgery

›Chronic liver disease

›Cirrhosis

›Portal hypertension

›Cardiac disease

›Coronary artery disease (I25.10)

›Heart failure (I50.9)

›Pregnancy status

›Gestational age

›Obstetric complications

10Physical Exam/exam32

General and vitals

›General assessment

›Ill appearance

›Toxic appearance

›Diaphoresis

›Hydration status

›Vital sign pattern

›Fever

›Tachycardia

›Hypotension

Abdominal and hepatobiliary

›Abdominal exam cluster

›Right upper quadrant tenderness

›Epigastric tenderness

›Murphy sign

›Guarding

›Rebound tenderness

›Distension

›Hepatomegaly

›Palpable gallbladder

›Bowel sounds abnormality

Skin cardiopulmonary and neuro

›Focused exam cluster

›Scleral icterus

›Jaundice

›Excoriations from pruritus

›Chest exam

›Right lower lobe crackles

11Lab Studies/labs32

Core laboratory evaluation

›Baseline labs for biliary pathology

›CBC

›Leukocytosis support for cholecystitis

›Hemolysis clues if pigment stones suspected

›Electrolytes and renal function

›Dehydration assessment

›Renal dosing prompts

›Liver enzymes and bilirubin

›AST and ALT

›Alkaline phosphatase

›GGT

›Total bilirubin

›Direct bilirubin

›Lipase

›Pancreatitis support

›Mild elevation nonspecific

›Lactate

›Sepsis physiology

›Mesenteric ischemia concern

›CRP

›Inflammatory severity support

›Trend utility

›Blood cultures

›Fever with suspected cholangitis

›Before antibiotics when feasible

Pregnancy and metabolic modifiers

›Special population labs

12Imaging/img52

Scoring Systems

›Severity and risk tools

›Tokyo Guidelines acute cholecystitis severity

›Grade I mild

›Grade II moderate

›Grade III severe with organ dysfunction

›ASGE risk stratification for choledocholithiasis

›High probability features

›Intermediate probability features

›Low probability features

›Limitations

›Local protocol dependent operational definitions

›Does not replace clinical judgment in shock

MRI

›MRI and MRCP use cases

›MRCP for suspected choledocholithiasis

›Cholestatic lab pattern

›Ductal dilation on ultrasound

›Pregnancy preferred cross sectional imaging when available

›Avoid gadolinium unless essential

›Local protocol dependent

›Interpretation pearls

›Common bile duct stone visualization

›Stricture and malignancy differentiation prompts

›CT abdomen pelvis role

›Complications suspected

›Perforation

13Special Tests/spec14

Functional and adjunct diagnostics

›Additional tests when ultrasound nondiagnostic

›HIDA scan

›Nonvisualization consistent with acute cholecystitis

›Delayed filling supportive of chronic cholecystitis

›Endoscopic ultrasound

›Intermediate risk choledocholithiasis

›Small duct stones detection

›ERCP diagnostic and therapeutic

›High probability choledocholithiasis

›Ascending cholangitis urgent decompression

Bedside maneuvers and reassessment

›Serial bedside reassessment

›Pain trajectory after analgesia

›Evolving peritoneal signs

›Worsening jaundice or mental status change

14ECG/ecg10

When epigastric pain may be cardiac

›ECG indications

›Epigastric pain with diaphoresis

›Chest radiation

›Older age

›Diabetes mellitus

›Hypotension

›Abnormal vitals without clear abdominal source

›Serial ECG logic

›Persistent symptoms with initial nondiagnostic ECG

›Troponin pathway local protocol dependent

15Assessment/ax25

Working diagnoses and key distinctions

›Biliary colic (K80.20)

›Pain episodes less than 6 hours

›Afebrile

›Minimal tenderness between episodes

›Normal or near normal inflammatory markers

›Acute cholecystitis (K81.0)

›Persistent right upper quadrant pain more than 6 hours

›Fever or leukocytosis

›Murphy sign or localized peritonism

›Ultrasound inflammatory features

›Choledocholithiasis (K80.50)

›Jaundice

›Cholestatic lab pattern

›Ductal dilation

›Ascending cholangitis (K83.09)

›Systemic toxicity

›Fever with jaundice

›Hypotension or altered mental status

Complications to rule out

›Complication screen

›Gallstone pancreatitis (K85.1)

›Gallbladder perforation

›Emphysematous cholecystitis

›Hepatic abscess

›Sepsis

›Alternate life threat mimics

16Plan/plan62

First 5 minutes and stabilization

›Immediate workflow

›Triage to monitored setting if instability

›Continuous pulse oximetry

›Cardiac monitoring if systemic toxicity

›IV access

›Two large bore IV lines if hypotension or sepsis concern

›Single IV line if stable

›Fluids

›If hypotension then isotonic crystalloid bolus 500 mL to 1000 mL

›Reassess after each bolus for overload risk

›Analgesia initiation

›Ketorolac IV 15 mg

›Avoid ketorolac if renal impairment or GI bleed risk

›Hydromorphone IV 0.2 mg to 0.5 mg

›Repeat every 10 to 15 minutes to effect with monitoring

›Antiemetic

›Ondansetron IV 4 mg

›Repeat once if persistent

›Antibiotics only when infection suspected

›Early antibiotics if cholecystitis with systemic features

›Immediate antibiotics if cholangitis suspected

Differential Management

›!Cholecystitis→›!Choledocholithiasis and cholangitis→›Acute pancreatitis→

Diagnostic sequencing

›Workup pathway

17Disposition/dispo28

Admission and procedural pathways

›Level of care decision

›ICU criteria

›Persistent hypotension after fluids

›Vasopressor requirement

›Altered mental status from sepsis

›Lactate persistently elevated with shock physiology

›Inpatient admission criteria

›Acute cholecystitis with systemic signs

›Suspected choledocholithiasis requiring MRCP or ERCP

›Gallstone pancreatitis

›Uncontrolled pain or vomiting

›Inability to tolerate oral intake

›Significant comorbidity or frailty

›Observation pathway criteria

›Equivocal imaging with persistent symptoms

›Need for serial exams and repeat labs

›Discharge criteria

›Pain controlled on oral medications

›Tolerating oral fluids

›No fever

›No jaundice

›Reassuring labs and imaging

›Reliable follow up within 48 to 72 hours

Follow up timing

›Follow up plan

›Surgery referral for symptomatic cholelithiasis

›Timing within 1 to 2 weeks if recurrent biliary colic

18Discharge Instructions/di21

Copy discharge instructions

›Discharge text

›Diagnosis likely biliary colic from gallstones

›Return now for fever

›Return now for worsening or constant pain lasting more than 6 hours

›Return now for yellowing of eyes or skin

›Return now for dark urine or pale stools

›Return now for persistent vomiting or inability to keep fluids down

›Return now for fainting or severe weakness

›Diet for next 48 hours

›Low fat foods

›Small frequent meals

›Medications

›Acetaminophen as directed on label

›Avoid NSAIDs if kidney disease or stomach bleeding history

›Avoid alcohol while taking pain medicines

›Follow up

›Surgical consultation for gallbladder removal

›Primary care follow up within 1 week

›Safety

›Do not drive after opioid pain medication

›Seek care sooner if symptoms are changing quickly

19References/r6

Guidelines and evidence

›Evidence sources

›Tokyo Guidelines for management of acute cholecystitis and acute cholangitis 2018

›World Society of Emergency Surgery guidelines for acute calculous cholecystitis 2020

›American Society for Gastrointestinal Endoscopy guideline on choledocholithiasis risk stratification and ERCP indications 2019

›American College of Radiology Appropriateness Criteria right upper quadrant pain 2023

›Surviving Sepsis Campaign guidelines 2021

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.