GI

Biliary Colic

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Biliary Colic

  • Pathophysiology
  1. See Gallstone
  2. Brief (<5 hours) of Gallstone impaction in the neck of the gallbladder
  • 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)
  • 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
  • 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
  • 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
  • Imaging
  • Other studies
  1. XRay Abdomen
    1. Test Sensitivity: 10-20% for Gallstones
  2. Chest XRay normal
  • 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
  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)
  • Course
  1. Recurrent Biliary Colic
    1. Within 2 years of initial attack: 66%
    2. Within 10 years of initial attack: 90%