GI
Biliary Colic
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Biliary Colic
See Also
Gallstone
(
Cholelithiasis
)
Acute Cholecystitis
Choledocholithiasis
Acute Gallstone Cholangitis
(
Ascending Cholangitis
)
Acalculous Cholecystitis
Pathophysiology
See
Gallstone
Brief (<5 hours) of
Gallstone
impaction in the neck of the gallbladder
Symptoms
Abdominal Pain
characteristics
RUQ Abdominal Pain
or
Epigastric Abdominal Pain
(T8 and T9
Dermatome
s)
Dull visceral ache of moderate to severe intensity
Poorly localized discomfort
Pain radiates to right posterior
Shoulder
or
Scapula
Abdominal Pain
timing:
Occurs suddenly 30-60 minutes after a meal
Normal meal
Large meal after a fast
Fatty meal
Increasing frequency and intensity of attacks
Steady, non-fluctuating pain
Intensity peaks within 1 hour and lasts for up to 5 hours until the
Gallstone
dislodges
Intermittent "colicky" exacerbations of pain
Mild abdominal aching for 1-2 days after attack
Associated symptoms
Nausea
and
Vomiting
No
Fever
or chills (see differential diagnosis)
Signs
RUQ abdominal tenderness
Tenderness may persist for days after a Biliary Colic episode
No signs of peritoneal irritation
Distinguishes Biliary Colic from
Acute Cholecystitis
Dehydration
from protracted
Vomiting
Differential Diagnosis
Acute Cholecystitis
Ascending Cholangitis
Pancreatitis
Labs
Complete Blood Count
usually normal
Mild elevation of
Liver Function Test
s
Bilirubin
slightly elevated
Alkaline Phosphatase
slightly elevated
Pancreatic Enzyme
tests normal
Amylase normal
Lipase
normal
Urinalysis
normal
HCG normal
Imaging
Primary studies
Gallbladder Ultrasound
Test Sensitivity
: 95% for
Gallstone
s
However no
Gallstone
s are found on
Ultrasound
despite classic Biliary Colic in 20% of cases
May be related to small gall stone size, composition or decreased gallbladder ejection fraction
Cholecystokinin-HIDA Scan
(
Radionuclide Hepatobiliary Study with CCK
)
Indicated for normal or equivocal
Gallbladder Ultrasound
(evaluate for
Biliary Dyskinesia
)
Symptoms reproduced with
Cholecystokinin
(CCK) injection are suggestive of Biliary Colic
Imaging
Other studies
XRay
Abdomen
Test Sensitivity
: 10-20% for
Gallstone
s
Chest XRay
Consider for evaluation of differential diagnosis of
RUQ Abdominal Pain
(e.g.
Pneumonia
)
Consider for exclusion of free air under the diaphragm (viscus perforation)
Management
Medical
Analgesic
s: Home
NSAID
s (preferred first line option)
Opioid
s (for pain not relieved with
NSAID
s)
Analgesic
s: Emergency department
Ketorlac (
Toradol
)
Relieves pain of gallbladder distention
Not as effective if infection present
Opioid
s (e.g.
Hydromorphone
)
Meperidine
(
Demerol
) is reported to cause less sphincter of Oddi spasm than
Morphine
However, typically other
Opioid
s in most scenarios are preferred over
Meperidine
Antispasmodic (
NSAID
s are preferred)
Scopolamine
Glycopyrrolate (Robinul)
Parenteral
: 0.1 to 0.2 mg IV or IM
Oral: 1.0 to 2.0 mg orally bid to tid
Antiemetic
s
Ondansetron
(
Zofran
)
Promethazine
(
Phenergan
)
Nasogastric Suction
Indicated for protracted
Vomiting
Management
Definitive
Gallstone
management
Laparoscopic Cholecystectomy
Preferred option in most cases
Expectant management is also a reasonable strategy if no complications or contraindications (see
Gallstone
s for criteria)
May also consider
Cholecystectomy
in classic Biliary Colic symptoms without
Gallstone
s and nondiagnostic
HIDA Scan
Cholecystectomy
offers satisfactory symptom relief in 96% of cases
Brosseuk (2003) Am J Surg 186:1-3 [PubMed]
Alternatives in non-surgical candidates
Bile Acid Oral Dissolution Therapy
Ursodiol
or chenodexoycholic acid taken for 6-12 months
Indications
Non-surgical candidate AND Symptomatic
Gallstone
s or
Small
Gallstone
s (<5mm) with functioning gallbladder and no cystic duct obstruction
Extracorporeal Shock Wave Lithotripsy
(
ESWL
)
Course
Recurrent Biliary Colic
Within 2 years of initial attack: 66%
Within 10 years of initial attack: 90%
References
Abraham (2014) Am Fam Physician 89(10): 795-802 [PubMed]
Portincasa (2006) Lancet 368(9531):230-9 [PubMed]
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