Approximately 10% to 15% of adults have gallstones, resulting in more than 600,000 cholecystectomies being performed annually in the United States. It is not surprising, therefore, that biliary disease is a major consideration in the patient with acute abdominal pain. Although there is no substitute for skillful physical diagnosis, the radiologist is often the central player in the evaluation of biliary disease. This article focuses on three specific areas of importance to the radiologist: (1) the diagnostic approach to acute biliary disease, (2) imaging of specific clinical entities, and (3) the relationship between imaging findings and the use of new therapeutic modalities.