A- Gallstones in gallbladder B- Bile duct obstruction due to gall stones C- Premature activation and leakage of pancreatic enzymes This middle-aged woman has the typical symptoms of biliary colic, which is intermittent crampy abdominal pain in the epigastric region of the RUQ, sometimes radiating to the right shoulder. These symptoms typically appear after meals, paicularly fatty meals. The more concerning signs are the light-colored stools (acholic) and jaundice (icterus). Gallstones (cholelithiasis) are precipitated bile salts in the gallbladder, which may produce inflammation of the gallbladder (cholecystitis). Stones can pass into the cystic duct and into the common bile duct. Since the common bile duct is formed by the union of the cystic and common hepatic ducts, obstruction of the common bile duct prevents bilirubin produced in the liver from reaching the small intestines. The stools thus lack this pigment. As a secondary result of the obstruction, serum bilirubin is elevated, and precipitates in the skin, resulting in the yellow tint. Ultrasound (DOUBLE BARREL/DUCT SIGN) can often make the initial diagnosis. Removal of a common bile duct stone can be performed by upper GI endoscopy through the ampulla of Vater or surgically.