Abdominal Pain and Gall bladder disorders Flashcards
Prevalence of abdominal pain
Most common complaint in emergency departments
Among the top 10 complaints in outpatient settings
What is an acute abdomen?
Acute Abdomen
-Refers to any acute condition requiring immediate medical or surgical attention
-May be of non-abdominal origin and not always require surgery
-Majority of patients presenting with abdominal pain do not have an acute abdomen
What are the surgical causes of abdominal pain?
Appendicitis
Cholecystitis
Bowel obstruction
Acute mesenteric ischemia
Perforation
Trauma
Peritonitis
What is the most common diagnosis of abdominal pain?
Nonspecific abdominal pain (NSAP) is the most frequent diagnosis in emergency departments.
Most patients with NSAP likely have gastroenteritis
What are the medical causes of abdominal pain?
Cholangitis
Pancreatitis
Choledocholithiasis
Diverticulitis
PUD
Gastroenteritis
Nonabdominal causes Functional cause
FUNCTIONAL (chronic) ( more of chronic)
What are the common causes of abdominal pain?
Gastrointestinal conditions: Gastroenteritis, gastritis, peptic ulcer disease, GORD, IBS, diverticulitis, pancreatitis, ischemic bowel disease
Gynecological conditions: Dysmenorrhea, salpingitis, ovarian torsion, ectopic pregnancy
Surgical conditions: Appendicitis, cholecystitis, cholelithiasis, intestinal obstruction, incarcerated hernias, mesenteric adenitis
Other causes: Ureterolithiasis, gas entrapment syndromes, bowel embolisation/infarction, dissecting/ruptured aneurysms
What are the considerations to consider when making a diagnosis of abdominal pain?
Clinician should assess:
Age, gender, medical history
Pain characteristics: location, radiation, aggravating factors
Associated symptoms: vomiting, bowel habit changes, fever, chills
Physical examination findings
When a patient presents with abdominal pain what are the alarm signs suggesting serious disease?
Unintentional Weight loss
GI bleeding
Anemia
Fever
Frequent nocturnal symptoms
Symptom onset in patients >50 years
Enlarged supraclvicular lymph nodes
Family history of serious bowel disease
What are the surgical emergencies of abdominal pain?
Common conditions requiring surgery:
Appendicitis
Cholecystitis
Perforated peptic ulcer
Other surgical conditions:
Acute intestinal obstruction
Visceral torsion/perforation
Tumors
Ruptured aneurysms
Mesenteric occlusion
What is the best-test method of abdominal pain?
Identifies specific symptoms highly correlated with diagnosis
Examples:
RUQ pain= Cholecystitis
Pain aggravated by movement =Appendicitis or perforated ulcer
Pain with coughing/movement =Peritoneal inflammation (e.g., appendicitis)
Palpable mass= Diverticular disease
Hyperactive bowel sounds =Small bowel obstruction
Reduced bowel sounds=Perforation
Involuntary guarding (RLQ) =Appendicitis
What is the nature of pain in abdominal conditions?
3 Types of Visceral Pain
Tension Pain : Often colicky due to increased peristalsis
Inflammatory Pain : Localized due to parietal peritoneum involvement (e.g., appendicitis)
Ischemic Pain : Sudden, intense, progressive, and unrelieved by analgesics
What are the patterns of pain in Biliary colic?
- Develops in the evening
- Steady midepigastric or right upper quadrant (RUQ) pain
What are the patterns of pain in Appendicitis?
Begins as colicky pain in mid-abdomen, then localises to constant pain in the right lower quadrant (RLQ)
What are the patterns of pain in Cholelithiasis & Cholecystitis?
Start as crampy or colicky pain
Localises in the RUQ
What are the patterns of pain in Intestinal Obstruction & Ureterolithiasis?
- Colicky pain that progresses to severe, constant pain
- Ureterolithiasis pain radiates to groin, testes, or medial thigh
What are the patterns of pain in Peptic Ulcer Disease?
Pain Characteristic:
Constant, burning, or gnawing pain
Located in midepigastrium, sometimes radiating posteriorly
Worse at night (though uncommon)
Not aggravated by lying down
Atypical Presentations in Older Patients:
Vague and poorly localised pain
Perforation leading to peritonitis is more common
Epigastric pain on percussion may be the only sign
What are the patterns of pain in gallbladder inflammation?
Severe pain exacerbation with percussion over RUQ suggests cholecystitis
What are the patterns of pain in Irritable Bowel Syndrome (IBS) ?
- 12 weeks of symptoms within the past year
- Dull, crampy, recurrent pain
- Associated with:
Changes in stool frequency or form
Bloating
Alternating constipation and diarrhea
Small stools with mucus - Moderate pain may be elicited on colon palpation
What condition can mimic IBS?
Severe diverticulitis can mimic IBS, especially in older adults
What does abrupt-onset severe abdominal pain suggest?
Suggestsperforation, strangulation, torsion, dissecting aneurysm, or ureterolithiasis
Where does the most severe abdominal pain occur in?
Dissecting Aneurysm:
Tearing or ripping pain
Radiates to legs, back, and torso
Often accompanied by profound shock
Ureterolithiasis:
Excruciating, unilateral flank, groin, or testicular pain
Associated with nausea and occasional vomiting
Writhing in agony but no cardiovascular collapse
Summarise all the conditions associated within each region of the abdominal wall.
What are the most common causes of right upper quadrant pain?
Cholecystitis
Cholelithiasis
Leaking duodenal ulcer
RUQ pain radiating toinferior angle of the right scapulasuggestsgallbladder disease
What are the other conditions that can cause RUQ?
Hepatitis
Congestive heart failure (CHF)
Due to liver swelling andGlisson capsule distention
Myocardial infarction (MI)
Can manifest as RUQ pain
Hepatic flexure syndrome(gas entrapment in the hepatic flexure of the colon)
Less severe RUQ pain
Pain relieved with passage of flatus
What are conditions associated with mid abdominal to upper abdominal pain?
Gnawing, burning pain suggests peptic etiology:
Peptic ulcer
Gastritis
Esophagitis
Burning epigastric pain radiating to the jaw:
-Peptic esophagitis
Severe upper abdominal pain radiating to the back, associated with nausea and vomiting:
Pancreatitis
-Worsens whenlying down
-Improves whenleaning forward
What are the most common causes of left upper quadrant pain?
Gastroenteritis
Irritable bowel syndrome (IBS)
What are the less common causes of LUQ?
Splenic flexure syndrome
May also present aschest pain
Triggered bybending over or wearing tight garments
Relieved by passage of flatus
Splenic infarction
Pancreatitis
Colonic obstruction(in patients with a competent ileocecal valve)
What are the conditions associated with both RUQ and LUQ?
Due to supradiaphragmatic conditions with diaphragm inflammation:
Pneumonia
Pulmonary embolism
Pleurisy
Pericarditis
What are the most common causes of RLQ pain?
Muscle strain
Appendicitis
Salpingitis
Diverticulitis(though more common in LLQ
Less common causes:
Ileitis
Terminal ileitis (Crohn’s disease)
Pyelonephritis
Obturator hernia
Carcinoma of the cecum
What are the associated symptoms of abdominal pain?
Vomiting BEFORE pain onset→ Less likely to be an acute abdomen
Vomiting AFTER pain onset→ More concerning for an acute abdomen
-Common inappendicitis
-Absence of vomiting doesnotrule out acute abdomen
What are the characteristics of Vomitus?
Light-colored, digestive juices, bile→Gastritis, cholecystitis, obstruction
Undigested food→Proximal obstruction(achalasia, peptic esophagitis)
Brown, faecal-smelling vomit→Bowel obstruction (mechanical/paralytic)
What are the Biliary and liver related symptoms?
Jaundice + dark urine + pale stools
→Obstructive jaundice
Silver-colored stools(alternating with normal)
→Carcinoma of the Ampulla of Vater
What can bowel habits and pain suggest?
Constipation with small, dry stools alternating with diarrhoea
→IBS
Diarrhoea + constant pain in >40 y/o
→ referral ?cause
What are the things to consider during a physical examination?
Inspection→ Distention, pulsations, abnormal abdominal movements
Auscultation→ Listen to bowel soundsbeforepalpation
Palpation→ Start away from pain, move toward tenderness
Percussion→ Check for tenderness, peritonitis
What are the key diagnostic signs of an abdominal examination?
Rebound tenderness→Peritoneal irritation
Pain worsens with deep inspiration/coughing→Peritonitis
Rigidity, guarding, motionless posture→Severe peritonitis
Absent bowel
sounds→Paralytic ileus, severe peritonitis
Hypotension, tachycardia, pallor, sweating→Shock due to peritonitis
What is Acute cholecystitis?
Acute cholecystitis is the sudden inflammation of the gallbladder, usually caused by a gallstone blocking the cystic duct. This obstruction leads to bile buildup, causing gallbladder irritation, inflammation, and sometimes infection.
What is acute cholecystitis caused by?
It develops in up to 10% of patients with symptomatic gallstones.
In most cases (90%), it is caused by complete cystic duct obstruction usually due to an impacted gallstone in the gallbladder neck or cystic duct, which leads to inflammation within the gallbladder wall.
In 5% of cases, bile inspissation (due to dehydration) or bile stasis (due to trauma or severe systemic illness) can block the cystic duct, causing an acalculous cholecystitis.
What is the epidemiology of acute cholecystitis?
Acute cholecystitis commonly affects adults aged 40–60, with a higher incidence in women due to hormonal risk factors for gallstones. It is more prevalent in Western and Hispanic populations, with obesity, diabetes, and rapid weight loss increasing the risk.
What is the aetiology of acute cholecystitis?
At least 90% of patients have gallstones.
Occasionally, acute cholecystitis occurs in the absence of gallstones.
Predisposing factors for acute acalculous cholecystitis:
- starvation
- total parenteral nutrition
- narcotic analgesics
- immobility
Secondary infection with gram- negative flora occurs in most cases of acute acalculous cholecystitis.
What is the difference between Calculous vs Acalculous cholecystitis?
Calculous cholecystitis is the most common type, caused by a gallstone blocking the cystic duct, leading to bile stasis, inflammation, and possible infection.
Acalculous cholecystitis occurs without gallstones, usually in critically ill patients (e.g., sepsis, trauma, burns) due to gallbladder stasis, ischemia, and infection.
What is calculous cholescystitis?
Fixed obstruction or passage of gallstones into the gallbladder neck or cystic duct leads to acute inflammation.
Impacted gallstone traps bile, causing irritation and increased pressure.
Mechanical trauma stimulates prostaglandin synthesis (PGI2, PGE2), driving inflammation.
Secondary bacterial infection can occur, leading to necrosis and gallbladder perforation.
What is Acalculous Cholecystitis?
Pathophysiology is not well understood but is likely multifactorial.
Functional cystic duct obstruction is often due to biliary sludge, dehydration, or bile stasis from trauma or systemic illness.
Extrinsic compression may contribute to bile stasis.
Some patients with sepsis develop direct gallbladder wall inflammation and ischemia without obstruction.
What is Mirizzi’s syndrome?
Mirizzi’s Syndrome is a rare complication of gallstone disease where a large gallstone becomes impacted in the cystic duct or gallbladder neck, causing compression of the common hepatic duct (CHD). This leads to bile duct obstruction and sometimes erosion, causing a fistula.
Occurs in up to 10% of patients.
What is the disease progression and complications of acute cholecystitis?
Acute cholecystitis may resolve spontaneously within 5–7 days if the impacted stone dislodges and cystic duct patency is restored.
If patency is not re-established, inflammation and pressure necrosis can occur, leading to:
-Mural and mucosal hemorrhagic necrosis
-Suppurative cholecystitis
-Gangrenous cholecystitis
-Emphysematous cholecystitis
What is the pathological classification of acute cholecystitis?
Pathological classification
1. Oedematous
2 to 4 days
Gallbladder tissue is intact histologically, with oedema in the subserosal layer.
- Necrotising
3 to 5 days
Oedema with areas of haemorrhage and necrosis
Necrosis does not involve the full thickness of the wall. - Suppurative
7 to 10 days
WBCs present within the gallbladder wall, with areas of necrosis and suppuration
Intra-wall abscesses involving the entire thickness of the wall
Pericholecystic abscesses present. - Chronic
Occurs after repeated episodes of mild attacks
Mucosal atrophy and fibrosis of the gallbladder wall. - Emphysematous
Air appears in the gallbladder wall due to infection with gas-forming anaerobes
Often found in diabetic patients.
What are the symptoms and signs of acute cholecystitis
Severe, steady pain in the right upper quadrant (RUQ) or epigastric area
Pain radiating to the right shoulder or back
Fever and chills
Nausea and vomiting
Murphy’s sign positive (pain and inspiratory arrest when pressing on RUQ during deep breath)
Jaundice (in severe or complicated cases)
What is Murphys sign?
Murphy’s sign is a clinical test for acute cholecystitis, where a positive result occurs when the patient experiences pain on deep inspiration with palpation of the right upper quadrant of the abdomen, indicating gallbladder inflammation.
What are the signs of inflammation and what do they indicate?
Test to confirm inflammatory markers. Raised inflammatory markers indicate infection or inflammation of the gallbladder and are a guide to severity
Signs of inflammation include:
- Fever
- Elevated white cell count
- Elevated C-reactive protein
- Elevated erythrocyte sedimentation rate
What are the diagnostic tests of acute cholecystitis after initial assesement?
Ultrasound: This is the first-line imaging modality to confirm the diagnosis of acute cholecystitis. It can identify:
Gallstones
Gallbladder wall thickening
Pericholecystic fluid (fluid around the gallbladder)
Signs of inflammation
If ultrasound is inconclusive, further imaging like CT scan or MRCP may be considered.
Laboratory tests:
Liver function tests (LFTs): Elevated levels can suggest biliary obstruction.
White blood cell count (WBC): Likely elevated in the presence of infection or inflammation.
What is the management of acute cholecysistitis?
Initial management:
Hospital admission is recommended for patients with suspected acute cholecystitis.
Antibiotics should be started if there is concern about infection (e.g., Ceftriaxone or Piperacillin-tazobactam).
Analgesia: Pain management is crucial, and NSAIDs or opioids may be used.
Surgical intervention:
Cholecystectomy (gallbladder removal) is the definitive treatment for acute cholecystitis and should ideally be performed within 72 hours of symptom onset.
In some cases, percutaneous cholecystostomy (drainage of the gallbladder) may be performed if surgery is not feasible, especially in high-risk patients or those who are critically ill.
Patients with severe sepsis, bile duct obstruction, or significant comorbidities should be referred to a specialist (e.g., gastroenterologist or surgeon).
When should sepsis be considered?
Sepsis Identification: Always consider sepsis when there is acute deterioration in an adult with clinical evidence or strong suspicion of infection
What are the Non-specific Symptoms of sepsis?
Non-specific Symptoms:
Sepsis may present with non-specific symptoms such as feeling acutely unwell with a normal temperature or more severe signs, including multi-organ dysfunction and shock.
What is the systematic approach for sepsis management?
Use tools like the National Early Warning Score 2 (NEWS2) to assess the risk of deterioration from sepsis. Apply clinical judgement and follow your institution’s local guidelines for sepsis management.
What should you consider when you suspect sepsis?
If you suspect sepsis, arrange for urgent review by a senior clinical decision-maker
Within 30 minutes: For critically ill patients (e.g., NEWS2 score of 7+, septic shock).
Within 1 hour: For severely ill patients (e.g., NEWS2 score of 5-6).
What is the management of Sepsis?
Sepsis Treatment: Start treatment promptly based on severity, urgency, and local protocols.
In the community: For patients with suspected infection at high risk of deterioration, refer them urgently to hospital care (e.g., blue-light ambulance in the UK).
What are the causes of sepsis?
Complications of:
cholecystitis
acute pancreatitis
perforated peptic ulcer
emphysematous cholecystitis
gangrenous cholecystitis
gallbladder perforation
How to manage acute cholecystitis summarised
- Palpate theright upper quadrantfor tenderness and mass, which may indicate local perforation. A distended, tender gallbladder is palpable in about 30-40% of patients.
- Assess forMurphy’s sign: Gently rest your hand along the costal margin and ask the patient to take a deep breath. Pain upon inspiration suggests cholecystitis. It’s a highly sensitive sign but has low specificity, especially in older adults.
- Jaundice: Look for signs of jaundice, which occurs in 10% of cholecystitis cases due to biliary tract pressure from a distended gallbladder.
- Monitor with NEWS2: Track and document: Respiratory rate,oxygen saturation(document FiO₂ or O₂ flow rate if supplemental oxygen is used),temperature,systolic blood pressure,heart rate, andlevel of consciousnessor signs of new-onset confusion.
What are the imaging findings for patients with sepsis presenting with cholecystitis
Irregular thickeningof the gallbladder wall.
Poor contrast enhancementof the gallbladder wall (interrupted rim sign).
Increased fatty tissue densityaround the gallbladder.
Gas in the gallbladder lumen or wall.
Intraluminal structures(e.g., flap or membrane).
Peri‐gallbladder abscess.
These findings may be underestimated inultrasoundimaging, so advanced imaging (CT/MRI) is needed for accurate diagnosis.
What is the priority in sepsis
Priority in Sepsis: The primary focus should be diagnosing and managing sepsis in patients presenting with symptoms of cholecystitis. UseCTorMRIto identify the cause if sepsis is suspected, with contrast-enhanced imaging preferred for diagnosing more severe conditions like gangrenous cholecystitis or gallbladder perforation.
What are the key ultrasound signs of acute cholecystitis
- Pericholecystic fluid.
- Distended gallbladder.
- Thickened gallbladder wall(>3 mm).
- Gallstones.
- Positive sonographic Murphy’s sign(although may be absent in gangrenous cholecystitis).
What are the risk factors of acute cholecystitis?
The 5 F’s:
1. Female
2. Forty (or older)
3. Fat
4. Fertile (having had multiple pregnancies)
5. Fair (lighter skin, more common in people of European descent)
What are the different imaging that can be used for acute cholecystitis?
MRCP: If ultrasound does not detect common bile duct stones but the bile duct appears dilated or liver function tests are abnormal, request(MRCP).
MRI: Thickening of the gallbladder wall(≥4 mm).
Enlarged gallbladder(long axis ≥8 cm, short axis ≥4 cm).
Presence ofgallstonesor retained debris.
Fluid accumulationaround the gallbladder.
Linear shadowsin the fatty tissue surrounding the gallbladder
Endoscopic Ultrasound:
ConsiderEUSif MRCP does not provide a clear diagnosis. EUS is particularly useful for detecting distal common bile duct stones and should be considered if MRCP is inconclusive but liver function tests are abnormal. However, EUS is invasive, so only proceed with a high level of suspicion.
CT for Emphsematous Cholecystitis: UseCTimaging to diagnoseemphysematous cholecystitis, where gas within the gallbladder wall is typically present.
Apart from with a full blood count to check for white cells and checking for CRP what other investigations do we do in acute cholecystitis?
Bilirubin:
elevation = acute focal cholestasis in adjacent liver tissue or be due to common bile duct stones
LFTs:
Request liver function tests to indicate whether further imaging is required, such as MRCP.
May show elevated bilirubin, alkaline phosphatase, and gamma glutamyl transferase due to acute focal cholestasis in adjacent liver tissue or due to common bile duct stones.
Alanine aminotransferase can also be elevated if a stone has passed down the common bile duct, or if there is focal inflammation of the liver parenchyma in severe cholecystitis.
Why do we also check for serum lipase or amylase?
Serum lipase or amylase:
Identify or exclude the presence of acute pancreatitis. Use serum lipase testing (if available) in preference to serum amylase
A result>3 times the upper limit of the normal range confirms the diagnosis of acute pancreatitis in a patient with acute upper abdominal pain.
Serum lipase and amylase have similar sensitivity and specificity but lipase levels remain elevated for longer (up to 14 days after symptom onset versus 5 days for amylase), providing a higher likelihood of picking up the diagnosis in patients with a delayed presentation.
There are no blood tests that will specifically confirm the diagnosis of cholecystitis but they help to create a clinical picture of how unwell the patient and help to narrow down the differential diagnoses.
When are blood cultures or bile cultures requested?
If sepsis is suspected
What are the main treatment goals for acute cholecystitis?
The main treatment goals are to:
Manage sepsis, if suspected
Provide supportive treatment to reduce the risk of progression to organ failure and/or local complications
Treat the underlying cause
Manage local complications.
Treat patients with acute cholecystitis in hospital.
Referral to ED for review by Gen Surg team
Transfer patients to a specialist unit with surgeons
What is the treatment of acute cholecystitis?
In all patients:
- give analgesia
- fluid resuscitation
- antibiotics (if infection is suspected) (Follow local protocol / guidelines)
Most patients will require surgery.
- Laparoscopic cholecystectomy / percutaneous cholecystostomy / endoscopic US guided gallbladder drainage
- Patients should benil by mouthto rest the gallbladder and because of the likelihood of imminent surgery.
- Recommended surgery within 72 hours up to a week (if delayed surgery)
- In patients withsevere cholecystitis, manage organ dysfunction in an intensive care unitprior to surgery.
What are the possible complications of acute cholecystitis??
- Gall bladder empyema which is the most severe form and can result when cholecystitis is left to progress with concurrent bile stasis and cystic duct obstruction. It is a surgical emergency.
- Gall bladder perforation
- Acute cholangitis which occurs when biliary stenosis results in cholestasis and biliary infection. The stenosis/blockage may be due to benign causes such as bile duct stone or a tumour. This increases the pressure within the biliary system and flushes the micro-organisms or endotoxins from the infected bile into systemic circulation which causes a systemic inflammatory response.
What is the follow up of patients who undergo a cholecystectomy?
Patients who undergo cholecystectomy should be seen within 2 weeks after discharge from hospital.
Patients should be asked about presence or absence of nausea, vomiting, and abdominal pain, as well as their ability to tolerate oral intake.
The wound should be reviewed for erythema, discharge, or pain
any signs of jaundice should be noted; if such signs are present, the direct and indirect bilirubin level should be determined and an abdominal ultrasound ordered.
In patients who have undergone percutaneous cholecystostomy, if no gallstones are present and cholangiogram showed a patent cystic duct, the tube should be removed in 6 to 8 weeks.
What is the prognosis of acute cholecystitis?
Removing the gallbladder and the contained gallstones when biliary pain starts will prevent further biliary attacks and reduce the risk of developing cholecystitis.
If the gallbladder perforates, mortality is 30%.
Untreated acute acalculous cholecystitis is life-threatening and is associated with up to 50% mortality.
What is Charcot’s Triad?
Fever, Jaundice and RUQ pain.
It normally suggests acute cholangitis.
What is acute cholangitis?
Acute cholangitis (also calledascending cholangitis) is abacterial infectionof the biliary tree, usually due tobiliary obstruction. It is amedical emergencythat can lead to sepsis and requires urgent treatment.
What are the common causes of Acute cholangitis ?
Choledocholithiasis (gallstones in the bile duct) – Most common cause (85%)
Biliary strictures (post-surgical, primary sclerosing cholangitis)
Malignancy (pancreatic or cholangiocarcinoma)
Parasitic infections (Ascaris, Clonorchis
What are the common pathogens of acute cholangitis?
Gram-negative bacteria: Escherichia coli (most common), Klebsiella, Enterobacter
Gram-positive bacteria: Enterococcus
Anaerobes: Bacteroides
What is Reynolds’s Pentad?
Charcots’s triad plus hypotension and confusion which ultimately suggest sepsis.
What the common symptoms and signs?
Right upper quadrant pain and tenderness
High fever, rigors
Jaundice
Nausea and vomiting
Dark urine, pale stools (suggesting biliary obstruction)
What are the severe features which are suggestive of septic cholangitis?
Confusion
Hypotenuse
Tachycardia
Multi-organ failure
How is acute cholangitis diagnosed?
Imaging:
Ultrasound is the first-line investigation, but MRCP is the gold standard for detecting biliary obstruction and stones. -Bile duct dilation (>6 mm), stones, sludge
CT abdomen: May identify abscess, malignancy or complications
Blood Tests:
Raised white cell count and C-reactive protein (infection)
Raised bilirubin, alkaline phosphatase, and gamma-glutamyl transferase (biliary obstruction)
Mildly raised aspartate transaminase/alanine transaminase (hepatic involvement)
Blood cultures may be positive in 50-70% of cases
What is the emergency management of acute cholangitis if sepsis is present?
- Resuscitation with intravenous fluids
- Broad-spectrum intravenous antibiotics as soon as possible
- First-line:Piperacillin-Tazobactam (Tazocin)
- Alternative (penicillin allergy):Cefuroxime + Metronidazole - Intravenous analgesia (paracetamol ± opioids)
- Close monitoring for worsening sepsis
What is the definitive treatment of acute cholangitis?
Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone removal is the gold standard treatment. Surgery (cholecystectomy) is considered later to prevent recurrence if gallstones are the cause.
Mild cases may resolve with antibiotics alone, but severe cases require urgent ERCP within 24-48 hours.
