Biliary Colic

Aka: Biliary Colic, Symptomatic Gallstone

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II. Pathophysiology

  1. See Gallstone
  2. Brief (<5 hours), transient Gallstone impaction in the neck of the gallbladder

III. Precautions

  1. Distinguishing Biliary Colic from Acute Cholecystitis may require close interval repeat evaluations (<24 hours)

IV. Symptoms

  1. Abdominal Pain characteristics
    1. RUQ Abdominal Pain or Epigastric Abdominal Pain (T8 and T9 Dermatomes)
    2. Dull visceral ache of moderate to severe intensity
    3. Poorly localized discomfort
    4. Pain radiates to right posterior Shoulder or Scapula
  2. Abdominal Pain timing:
    1. Occurs suddenly 30-60 minutes after a meal
      1. Fatty meal (most common association)
      2. Large meal after a fast
      3. May alsi occur after a normal meal
    2. Increasing frequency and intensity of attacks
    3. Steady, non-fluctuating pain
    4. Intensity peaks within 1 hour and lasts for up to 5 to 6 hours until the Gallstone dislodges
      1. Differentiate from Acute Cholecystitis which typically persists >6 hours
    5. Intermittent "colicky" exacerbations of pain
    6. Mild abdominal aching for 1-2 days after attack
  3. Associated symptoms
    1. Nausea and Vomiting
    2. No Fever or chills (see differential diagnosis)

V. Signs

  1. RUQ abdominal tenderness
    1. Tenderness may persist for days after a Biliary Colic episode
  2. No signs of peritoneal irritation
    1. Distinguishes Biliary Colic from Acute Cholecystitis
  3. Dehydration from protracted Vomiting

VI. Differential Diagnosis

  1. See Right Upper Quadrant Abdominal Pain
  2. Acute Cholecystitis
  3. Ascending Cholangitis
  4. Acute Pancreatitis (or Gallstone Pancreatitis)

VII. Labs

  1. Complete Blood Count usually normal
  2. Mild elevation of Liver Function Tests
    1. Bilirubin slightly elevated
    2. Alkaline Phosphatase slightly elevated
  3. Pancreatic Enzyme tests normal
    1. Amylase normal
    2. Lipase normal
  4. Urinalysis normal
  5. HCG normal

VIII. Imaging: Primary studies

  1. Gallbladder Ultrasound
    1. Test Sensitivity: 95% for Gallstones
    2. However no Gallstones are found on Ultrasound despite classic Biliary Colic in 20% of cases
      1. May be related to small gall stone size, composition or decreased gallbladder ejection fraction
  2. Cholecystokinin-HIDA Scan (Radionuclide Hepatobiliary Study with CCK)
    1. Indicated for normal or equivocal Gallbladder Ultrasound (evaluate for Biliary Dyskinesia)
    2. Symptoms reproduced with Cholecystokinin (CCK) injection are suggestive of Biliary Colic

IX. Imaging: Other studies

  1. XRay Abdomen
    1. Test Sensitivity: 10-20% for Gallstones
  2. Chest XRay
    1. Consider for evaluation of differential diagnosis of RUQ Abdominal Pain (e.g. Pneumonia)
    2. Consider for exclusion of free air under the diaphragm (viscus perforation)

X. Management: Medical

  1. Analgesics: Home
    1. NSAIDs (preferred first line option)
      1. Safe and aws effective as Opioids for Biliary Colic
      2. Fraquelli (2016) Cochrane Database Syst Rev 9(9):CD006390 +PMID: 27610712 [PubMed]
    2. Opioids (for pain not relieved with NSAIDs)
  2. Analgesics: Emergency department
    1. Ketorlac (Toradol)
      1. Relieves pain of gallbladder distention
      2. Not as effective if infection present
    2. Opioids (e.g. Hydromorphone)
      1. Meperidine (Demerol) is reported to cause less sphincter of Oddi spasm than Morphine
      2. However, typically other Opioids in most scenarios are preferred over Meperidine
  3. Antispasmodic (NSAIDs are preferred)
    1. Scopolamine
    2. Glycopyrrolate (Robinul)
      1. Parenteral: 0.1 to 0.2 mg IV or IM
      2. Oral: 1.0 to 2.0 mg orally bid to tid
  4. Antiemetics
    1. Ondansetron (Zofran)
    2. Promethazine (Phenergan)
  5. Nasogastric Suction
    1. Consider in protracted Vomiting

XI. Management: Definitive Gallstone management

  1. Laparoscopic Cholecystectomy
    1. Preferred option in most cases
    2. Expectant management is also a reasonable strategy if no complications or contraindications (see Gallstones for criteria)
    3. May also consider Cholecystectomy in classic Biliary Colic symptoms without Gallstones and nondiagnostic HIDA Scan
      1. Cholecystectomy offers satisfactory symptom relief in 96% of cases
      2. Brosseuk (2003) Am J Surg 186:1-3 [PubMed]
  2. Alternatives in non-surgical candidates
    1. Extracorporeal Shock Wave Lithotripsy (ESWL)
    2. Bile Acid Oral Dissolution Therapy
      1. Ursodiol or chenodexoycholic acid (or combined) taken for 6-12 months
      2. Decrease bile acid secretion and may promote Gallstone dissolution
        1. May decrease Gallstone volume as much as 60% in 1-2 years (but residual stones in 70% of patients)
        2. Petroni (2001) Aliment Pharmacol Ther 15(1): 123-8 [PubMed]
      3. Indications
        1. Non-surgical candidate AND Symptomatic Gallstones OR
        2. Small Gallstones (<5mm) with functioning gallbladder and no cystic duct obstruction OR
        3. Prophylactically, following Bariatric Surgery (asymptomatic patients)
          1. High risk of Gallstones with expected rapid weight loss
          2. Mulliri (2022) J Gastroenterol 57(8):529-39 +PMID: 35704084 [PubMed]

XII. Course

  1. Recurrent Biliary Colic
    1. Within 2 years of initial attack: 66%
    2. Within 10 years of initial attack: 90%

XIII. References

  1. Abraham (2014) Am Fam Physician 89(10): 795-802 [PubMed]
  2. Patel (2024) Am Fam Physician 109(6): 518-24 [PubMed]
  3. Portincasa (2006) Lancet 368(9531):230-9 [PubMed]

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