II. Pathophysiology
III. Symptoms
-
Abdominal Pain characteristics
- RUQ Abdominal Pain or Epigastric Abdominal Pain (T8 and T9 Dermatomes)
- 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
- Occurs suddenly 30-60 minutes after a meal
- Associated symptoms
IV. 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
V. Differential Diagnosis
VI. Labs
- Complete Blood Count usually normal
- Mild elevation of Liver Function Tests
- Bilirubin slightly elevated
- Alkaline Phosphatase slightly elevated
-
Pancreatic Enzyme tests normal
- Amylase normal
- Lipase normal
- Urinalysis normal
- HCG normal
VII. Imaging: Primary studies
-
Gallbladder Ultrasound
- Test Sensitivity: 95% for Gallstones
- However no Gallstones 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
VIII. Imaging: Other studies
- XRay Abdomen
- Test Sensitivity: 10-20% for Gallstones
-
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)
IX. Management: Medical
- Analgesics: Home
-
Analgesics: Emergency department
- Ketorlac (Toradol)
- Relieves pain of gallbladder distention
- Not as effective if infection present
- Opioids (e.g. Hydromorphone)
- Meperidine (Demerol) is reported to cause less sphincter of Oddi spasm than Morphine
- However, typically other Opioids in most scenarios are preferred over Meperidine
- Ketorlac (Toradol)
- Antispasmodic (NSAIDs 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
- Antiemetics
- Nasogastric Suction
- Indicated for protracted Vomiting
X. Management: Definitive Gallstone management
-
Laparoscopic Cholecystectomy
- Preferred option in most cases
- Expectant management is also a reasonable strategy if no complications or contraindications (see Gallstones for criteria)
- May also consider Cholecystectomy in classic Biliary Colic symptoms without Gallstones 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
XI. Course
- Recurrent Biliary Colic
- Within 2 years of initial attack: 66%
- Within 10 years of initial attack: 90%