Gallstone disease differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]


Gallstone disease must be differentiated from other diseases that cause right upper quadrant pain including gastroesophageal reflux disorder, peptic ulcer disease,hepatitis,sphincter of Oddi dysfunction,appendicitis, bile duct stricture, chronic pancreatitis, irritable bowel syndrome, ischemic heart disease, pyelonephritis, ureteral calculi and complications of gallstone disease include: acute cholecystitis, choledocholithiasis, acute pancreatitis, and acute cholangitis.

Differentiating Gallstone disease from other Diseases

  • Gallstone disease can manifest in a variety of clinical forms.
  • The presence of biliary colic is an important diagnostic feature to distinguish between gallstones and non-biliary stone disorders.
  • Patients who present with biliary colic are more likely to have gallstones detected on imaging. [1]
  • However, it is important to note that biliary colic can be concomitant in patients with other biliary disorders such as acute cholecystitis, choledocholithiasis, sphincter of Oddi dysfunction, and functional gallbladder disorder.[2][3]

Differential diagnosis

The differential diagnosis of diseases presenting with abdominal pain, fever and jaundice is discussed below.

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Jaundice Diarrhea GI Bleed Hypo-


Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute suppurative cholangitis RUQ + + + + + + N Ultrasound shows biliary dilatation/stents/tumor Septic shock occurs with features of SIRS
Acute cholangitis RUQ + + N Ultrasound shows biliary dilatation/stents/tumor Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis RUQ + + Hypoactive Ultrasound shows gallstone and evidence of inflammation Murphy’s sign
Acute pancreatitis Epigastric + ± ± + + N Pain radiation to back
Primary sclerosing cholangitis RUQ + + N ERCP and MRCP shows The risk of cholangiocarcinoma in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
Cholelithiasis RUQ/Epigastric ± ± Normal to hyperactive for dislodged stone Ultrasound shows gallstone Fatty food intolerance
Gastric causes Gastrointestinal perforation Diffuse + ± ± +, depends on site + + ± Hyperactive/hypoactive Air under diaphragm in upright CXR Hamman's sign
Intestinal causes Inflammatory bowel disease Diffuse ± ± ± Hematochezia Normal/ Hyperactive String sign on abdominal x-ray in Crohn's disease

Extra intestinal findings:

Whipple's disease Diffuse ± ± + ± Normal Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Hepatic causes Viral hepatitis RUQ + + + in Hep A and Hep E + in fulminant hepatitis +in acute + Normal Hep Aand Hep E have fecoral route of transmission and Hep B and Hep C transmits via blood transfusion and sexual contact.
Liver masses RUQ + + in Liver abscess ± + in Hepatocellular carcinoma + in sepsis + in Liver abscess + in Liver abscess Normal
Liver abscess RUQ + + + ± - + + ± Normal/hypoactive
Hepatocellular carcinoma/Metastasis RUQ + - + - - - - -
  • Normal
  • Hyperactive if obstruction present

Other symptoms:

Budd-Chiari syndrome RUQ ± ± + in liver failure leading to varices Normal Findings on CT scan suggestive of Budd-Chiari syndrome include: Ascitic fluid examination shows:
Peritoneal causes Spontaneous bacterial peritonitis Diffuse + + + in cirrhotic patients + ± + + Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
Ultrasound for evaluation of liver cirrhosis

To review a differential diagnosis for abdominal pain, click here


  1. Kraag N, Thijs C, Knipschild P (1995). "Dyspepsia--how noisy are gallstones? A meta-analysis of epidemiologic studies of biliary pain, dyspeptic symptoms, and food intolerance". Scand. J. Gastroenterol. 30 (5): 411–21. PMID 7638565.
  2. Portincasa P, Moschetta A, Palasciano G (2006). "Cholesterol gallstone disease". Lancet. 368 (9531): 230–9. doi:10.1016/S0140-6736(06)69044-2. PMID 16844493.
  3. Center SA (2009). "Diseases of the gallbladder and biliary tree". Vet. Clin. North Am. Small Anim. Pract. 39 (3): 543–98. doi:10.1016/j.cvsm.2009.01.004. PMID 19524793.

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