Surgery Book

Stomach Disorders


Biliary Colic

Aka: Biliary Colic
  1. See Also
    1. Gallstone (Cholelithiasis)
    2. Acute Cholecystitis
    3. Choledocholithiasis
    4. Acute Gallstone Cholangitis (Ascending Cholangitis)
    5. Acalculous Cholecystitis
  2. Pathophysiology
    1. See Gallstone
    2. Brief (<5 hours) of Gallstone impaction in the neck of the gallbladder
  3. 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. Normal meal
        2. Large meal after a fast
        3. Fatty 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 hours until the Gallstone dislodges
      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)
  4. 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
  5. Differential Diagnosis
    1. Acute Cholecystitis
    2. Ascending Cholangitis
    3. Pancreatitis
  6. 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
  7. 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
  8. 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)
  9. Management: Medical
    1. Analgesics: Home
      1. NSAIDs (preferred first line option)
      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. Indicated for protracted Vomiting
  10. 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. Bile Acid Oral Dissolution Therapy
        1. Ursodiol or chenodexoycholic acid taken for 6-12 months
        2. Indications
          1. Non-surgical candidate AND Symptomatic Gallstones or
          2. Small Gallstones (<5mm) with functioning gallbladder and no cystic duct obstruction
      2. Extracorporeal Shock Wave Lithotripsy (ESWL)
  11. Course
    1. Recurrent Biliary Colic
      1. Within 2 years of initial attack: 66%
      2. Within 10 years of initial attack: 90%
  12. References
    1. Abraham (2014) Am Fam Physician 89(10): 795-802 [PubMed]
    2. Portincasa (2006) Lancet 368(9531):230-9 [PubMed]

Biliary Colic (C0151824)

Definition (NCI_CTCAE) A disorder characterized by a sensation of marked discomfort in the gallbladder region.
Definition (NCI) Painful sensation in the gallbladder region.
Concepts Disease or Syndrome (T047)
SnomedCT 16317000, 197387008, 139309003, 247359004, 37389005, 102628000
English BILIARY PAIN, BILIARY COLIC, Biliary Colic, Colic biliary, Biliary pain, Pain biliary, Gallbladder Pain, bladder gall pain, Colic;biliary, biliary colic, gall bladder pain, Pain;gallbladder, biliary pain, colic biliary, pain gallbladder, Biliary colic (disorder), Hepatic colic (finding), Biliary colic, Hepatic colic, Biliary colic symptom, Gallbladder pain, Gallbladder pain (finding), bilious; colic, colic; bilious, colic; gallbladder, gallbladder; colic, Hepatic colic -RETIRED-, Biliary colic (finding), gallbladder pain
Italian Colica biliare, Dolore colecistico, Dolore biliare
Dutch biliaire koliek, biliaire pijn, pijn biliair, gal; koliek, galblaas; koliek, koliek; galblaas, koliek; gal, galblaaskoliek, galblaaspijn
French Douleurs biliaires, Colique biliaire, COLIQUE VESICULAIRE, DOULEUR BILIAIRE, Douleur biliaire, Douleur de la vésicule biliaire
German Gallenschmerz, Kolik Galle, GALLENKOLIK, GALLENSCHMERZ, Gallenblasenschmerzen, Gallenkolik
Portuguese Dor biliar, COLICA BILIAR, DOR BILIAR, Cólica biliar, Dor na vesícula biliar
Spanish Dolor biliar, cólico biliar (trastorno), BILIAR, COLICO, COLICO BILIAR, cólico hepático - RETIRADO - (concepto no activo), cólico hepático - RETIRADO -, cólico biliar, dolor de vesícula (hallazgo), dolor de vesícula, dolor vesicular, Cólico biliar, Dolor de la vesícula biliar, cólico biliar (hallazgo), cólico hepático
Japanese 胆嚢痛, 胆道痛, 胆道仙痛, タンドウセンツウ, タンドウツウ, タンノウツウ
Czech Biliární kolika, Biliární bolest, Žlučníková bolest, Bolest žlučníku
Hungarian epés fájdalom, Epekőroham, Biliaris fájdalom, Colica biliaris, Epehólyag fájdalom
Derived from the NIH UMLS (Unified Medical Language System)

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