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\b[The signs depend on the obstructed site: a stone in the cystic duct, the common <bile duct> and the outlet shared with the pancreatic duct can produce different syndromes.] “An impacted <gallstone>” is not enough anatomical information to choose a treatment.
A typical pain pattern is severe upper abdominal pain, often in the right upper quadrant or epigastrium, sometimes radiating to the back or shoulder, with <nausea> and <vomiting>. Despite the term “colic”, the pain can remain steady during an attack. Persistent focal tenderness with <fever> suggests <acute cholecystitis> rather than an uncomplicated transient obstruction. Cystic-duct obstruction does not necessarily obstruct hepatic <bile> flow and therefore need not produce <jaundice>.
A stone obstructing the common <bile duct> can produce <jaundice>, dark <urine> and pale stools. <Fever> or rigors with <jaundice> and biliary pain raises concern for <acute cholangitis>, while shock or altered awareness indicates serious illness. Obstruction at the distal outflow can precipitate <acute pancreatitis>, often with prominent pain radiating to the back and <vomiting>. These are patterns to investigate, not findings supplied by the examination; absence of a full classical combination does not exclude dangerous obstruction.<Gallstones by NIDDK>[Symptoms and causes; signs of complications and obstruction]{ref}
An 1866 clinician would try to establish the pain's origin, look for <jaundice>, observe the <urine> and stools, relieve severe pain, support fluid intake and watch for persistent obstruction or inflammation. Warm external applications and an opiate were among the symptomatic measures of the period. Passage of a recovered stone could strengthen the diagnosis, but failure to find one in the stool did not disprove it, and temporary relief did not demonstrate duct clearance. Neither a purgative nor an asserted stone-dissolving mixture could be assumed to free an impacted duct. These are reconstructions of the diagnostic and palliative aims available before modern duct imaging and endoscopic treatment, not a current management recipe.
\b[Modern correction: investigate promptly and relieve consequential obstruction, rather than treating the pain alone.] Obtain appropriate examination, <liver function tests> and <ultrasonography>. If suspicion of common-duct stones remains because of abnormal tests or duct dilatation despite no stone being shown, <magnetic resonance cholangiopancreatography> can clarify the ducts; <endoscopic ultrasonography> is an additional option when needed. Evaluate for <acute pancreatitis> and other causes of an acute abdomen. Relief of pain, fluid support and treatment of associated illness proceed alongside investigation.<Gallstone disease: diagnosis and management by NICE>[CG188, recommendations on liver function tests, ultrasound, MRCP and endoscopic ultrasound]{ref}
Symptomatic gallbladder stones generally lead to consideration of <laparoscopic cholecystectomy>; early surgery is recommended for suitable <acute cholecystitis>. Common-duct stones require duct clearance, endoscopically or surgically as appropriate.<Gallstone disease: diagnosis and management by NICE>[CG188, managing gallbladder stones and common bile duct stones]{ref} \b[<Acute cholangitis> requires urgent treatment of <infection> and biliary decompression.] <Antibiotics> and resuscitation do not remove an obstructing stone. Endoscopic drainage is generally preferred when feasible; stone removal may accompany it if the person's condition permits, while an unstable person may need decompression before a more extensive procedure.<ASGE guideline on the management of cholangitis>[2021, recommendations on endoscopic drainage, timing and drainage with stone removal versus decompression alone]{ref} This is why prolonged pain with <jaundice> or <fever> cannot safely be managed merely by repeating historical analgesic mixtures.
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