Biliary Colic


Article Author:
William Gossman
Nalin Dayal


Article Editor:
Marcelle Meseeha


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
11/8/2019 10:39:17 AM

Introduction

Biliary colic is a common presentation of a stone in the cystic duct or common bile duct of the biliary tree. Colic refers to the type of pain that "comes and goes," typically after eating a large, fatty meal which causes contraction of the gallbladder. However, the pain is usually constant and not colicky. Treatment of this disease is primarily surgical, involving removal of the gallbladder, typically using a laparoscopic technique. This medical condition does not typically require hospital admission.[1][2]

Etiology

Gallstones are formed within the gallbladder and may be composed of either cholesterol or bilirubin. These stones may stay in the gallbladder and remain asymptomatic or may enter the cystic duct or common bile duct where they may become lodged and cause pain when the gallbladder contracts. The pain typically arises after meals, when the gallbladder contracts to release bile into the duodenum to aid in digestion by emulsifying fats. Stones commonly exist within the gallbladder without symptoms, also referred to as asymptomatic cholelithiasis. Asymptomatic cholelithiasis typically requires no medical or surgical treatment and may be managed expectantly and does not require further follow up. However, if pain, nausea, or vomiting do present, most commonly as right upper quadrant (RUQ) abdominal pain, the patient may be diagnosed with symptomatic cholelithiasis and will require surgical evaluation.[3][4]

Epidemiology

It is estimated that somewhere between 10% to 20% of adults have gallstones, of which 1% to 3% of patients are symptomatic. In the United States, approximately 500,000 people require cholecystectomy due to all types of biliary disease. Biliary colic has a female predominance due to the influence of estrogen on the formation of gallstones. Obesity and elevated cholesterol are also strongly correlated to biliary colic and gallbladder disease.[5][6]

Pathophysiology

Gallstones are formed in the gallbladder and can be composed of cholesterol or bilirubin. Fatty meals cause the release of cholecystokinin (CCK) from the duodenum which subsequently causes contraction of the gallbladder.This contraction can expel stones from the gallbladder into the cystic duct or common bile duct. Less commonly, stones may also be formed within the common bile duct (CBD) and are referred to as primary CBD stones. These stones irritate the lining of the ducts, causing pain which notably is present during times of gallbladder and duct contraction.[7][8]

History and Physical

Patients typically present with postprandial pain that "comes and goes," hence the term colic. The pain is usually in the RUQ of the abdomen and may have radiation into the back. With uncomplicated biliary colic, patients will likely present only with pain. However, some may also report nausea and/or vomiting. These symptoms are accentuated after meals.

Biliary colic patients are afebrile and will commonly have no abnormal vitals in contrast to acute cholecystitis or cholangitis, which may present with fevers, tachycardia, or even hypotension if they progress to septic shock.

Patients with biliary colic will generally only have RUQ or epigastric tenderness on physical exam. Abdominal distension and rebound tenderness are less common. Jaundice is not seen with blockage of the cystic duct; however, it is common with blockage of the common bile duct due to an elevation of direct bilirubin.

Risk factors to ascertain for biliary colic:

  • Elderly patient
  • Pregnancy
  • North European descent
  • Recent weight loss
  • Obesity
  • Liver transplant

Evaluation

Laboratory tests to be ordered include a complete blood count (CBC) and a metabolic panel with liver function tests. It is important to have these tests to rule out more serious gallbladder pathology such as acute cholecystitis or cholangitis. With an elevated white blood cell (WBC) count, the suspicion of acute cholecystitis or ascending cholangitis rises. Elevated liver enzymes such as direct bilirubin, AST, ALT, ALP, and GGT suggest a stone or blockage in the common bile duct. Stones within the gallbladder or cystic duct typically do not produce any laboratory abnormalities.[2][9]

RUQ abdominal ultrasound is the first radiologic test to evaluate suspected biliary pathology. HIDA scans are useful in evaluating acute or chronic cholecystitis and biliary dyskinesia. Abdominal CT is less sensitive than ultrasound at evaluating stones within the gallbladder. However, CT scans are a common modality used by emergency room physicians for nonspecific severe abdominal pain, which may find gallstones present. MRCP may be used for better visualization of the biliary tree, especially when evaluating for choledocholithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) can be used to evaluate for common bile duct stones if all other imaging is equivocal. ERCP is also a therapeutic intervention for choledocholithiasis.

Classic findings on RUQ ultrasound for biliary colic include stones (size may vary) or stone shadow. Findings of pericholecystic fluid, thickened wall (greater than 0.4 cm), and distended gallbladder are more indicative of acute cholecystitis.

Treatment / Management

Management of biliary colic is primarily surgical. Medical management of biliary colic involves strict maintenance to a low-fat diet and supportive management with anti-emetics and pain control. There is no role for antibiotics in biliary colic as there is no infectious etiology, such as in acute cholecystitis or cholangitis. Oral ursodeoxycholic acid has also been used to help dissolve gallstones. Surgical intervention with laparoscopic cholecystectomy remains the gold standard. In patients who are poor surgical candidates, extracorporeal shockwave lithotripsy may be considered, but there is a considerable chance of stone recurrence. Open cholecystectomy is a less common approach, used in patients who are not candidates for laparoscopic surgery.[10][11]

Endoscopic retrograde cholangiopancreatography (ERCP) is a both diagnostic and therapeutic for common bile duct stones. Sphincterotomy of the Ampulla of Vater can assist in removing stones after ERCP and prevent future stones from becoming lodged in the common bile duct.

Patients with biliary colic do not necessarily require hospital admission. They may be treated symptomatically with a low-fat diet, pain control, and anti-emetics, and follow up for a laparoscopic cholecystectomy as an outpatient within a reasonable time-frame. However, if the patient has severe or intractable abdominal pain, hospital admission and more urgent surgical management are warranted for symptomatic relief. Other considerations for possible admission include large gallstones. Stones greater than 1 cm in size have a greater propensity to obstruct the cystic duct and may predispose to acute cholecystitis so should be treated with surgical management more urgently. If the patient is unable to tolerate anything by mouth (even liquid), admission should be considered.

Differential Diagnosis

  • Hepatitis
  • Cholangitis
  • Mesenteric ischemia
  • Pancreatitis
  • Renal calculi
  • Viral or bacterial gastroenteritis

Complications

  • Pancreatitis
  • Cholangitis
  • Gallbladder perforation

Pearls and Other Issues

Aside from symptomatic cholelithiasis, complications of gallstones include acute cholecystitis, cholangitis, and pancreatitis depending on the location of the stone in the biliary tree. These diseases are more serious and do require hospital admission and medical management.

Enhancing Healthcare Team Outcomes

Patients with biliary colic often present to the emergency room with vague complaints. Besides blood work, imaging studies are necessary. The diagnosis and management of this disorder require an interprofessional team. While the treatment of cholelithiasis and choledocholithiasis is established, there is also some evidence indicating that the condition can be prevented by changing diet and lifestyle. Anecdotal reports indicate that lowering the amount of fat in the diet may reduce biliary colic. Reducing body weight gradually has also been shown to lower the risk of biliary colic- hence the patient should be educated on the importance of a low-fat diet and regular exercise. These patients should be educated on the signs and symptoms of acute cholecystitis and when to seek medical help. For patients treated with surgery, the majority have an excellent outcome.[12][13] (Level V)


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Biliary Colic - Questions

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Which of the following medications is not indicated in biliary colic?



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Which of the following can treat the pain associated with biliary colic?



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A 40-year-old, female who is obese presents with 7 out of 10 right upper quadrant pain and nausea for 3 days. The pain is worse after meals and does not radiate. Physical exam shows only moderate tenderness. The patient's CBC, electrolytes, and liver function tests are all within normal limits. What is the next step in the management of this patient?



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Which of the following ultrasound findings is an indication for delaying operative management in a patient with gallstones?



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Biliary Colic - References

References

Baiu I,Hawn MT, Gallstones and Biliary Colic. JAMA. 2018 Oct 16     [PubMed]
Naim H,Hasan SA,Khalid S,Abbass A,DSouza J, Clinical Cholecystitis in the Absence of the Gallbladder. Cureus. 2017 Nov 10     [PubMed]
Saurabh S,Green B, Is hyperkinetic gallbladder an indication for cholecystectomy? Surgical endoscopy. 2018 Sep 12     [PubMed]
Wilkins T,Agabin E,Varghese J,Talukder A, Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia. Primary care. 2017 Dec     [PubMed]
Hedström J,Nilsson J,Andersson R,Andersson B, Changing management of gallstone-related disease in pregnancy - a retrospective cohort analysis. Scandinavian journal of gastroenterology. 2017 Sep     [PubMed]
Cervellin G,Mora R,Ticinesi A,Meschi T,Comelli I,Catena F,Lippi G, Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department: retrospective analysis of 5,340 cases. Annals of translational medicine. 2016 Oct     [PubMed]
Tsai TJ,Chan HH,Lai KH,Shih CA,Kao SS,Sun WC,Wang EM,Tsai WL,Lin KH,Yu HC,Chen WC,Wang HM,Tsay FW,Lin HS,Cheng JS,Hsu PI, Gallbladder function predicts subsequent biliary complications in patients with common bile duct stones after endoscopic treatment? BMC gastroenterology. 2018 Feb 27     [PubMed]
Wybourn CA,Kitsis RM,Baker TA,Degner B,Sarker S,Luchette FA, Laparoscopic cholecystectomy for biliary dyskinesia: Which patients have long term benefit? Surgery. 2013 Oct     [PubMed]
Değerli V,Korkmaz T,Mollamehmetoğlu H,Ertan C, The importance of routine bedside biliary ultrasonography in the management of patients admitted to the emergency department with isolated acute epigastric pain Turkish journal of medical sciences. 2017 Aug 23     [PubMed]
Demehri FR,Alam HB, Evidence-Based Management of Common Gallstone-Related Emergencies. Journal of intensive care medicine. 2016 Jan     [PubMed]
Bani Hani MN, Laparoscopic surgery for symptomatic cholelithiasis during pregnancy. Surgical laparoscopy, endoscopy     [PubMed]
Altieri MS,Yang J,Zhu C,Sbayi S,Spaniolas K,Talamini M,Pryor A, What happens to biliary colic patients in New York State? 10-year follow-up from emergency department visits. Surgical endoscopy. 2018 Apr     [PubMed]
Santucci NR,Hyman PE,Harmon CM,Schiavo JH,Hussain SZ, Biliary Dyskinesia in Children: A Systematic Review. Journal of pediatric gastroenterology and nutrition. 2017 Feb     [PubMed]

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