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Biliary Colic

Acute biliary colic can indicate a number of gallbladder pathologies that are related to gallstones but are managed in different ways. Biliary colic is a common ED presentation. The major challenge is to ensure that the patient doesn’t have serious secondary complications secondary to gallstones. i.e. Cholecystitis, Cholangitis, Pancreatitis, Septicaemia, Gallbladder gangrene and perforation. There are a number of similar sounding terms related to gallbladder pathologies that are very similar and commonly trip people up.

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 Biliary Colic Mimics: What you don’t want to miss

There are several biliary colic mimics including acute coronary syndrome, pneumonia, pulmonary embolism, acute hepatitis, bowel perforation, hepatic abscess, right sided diverticulitis, mesenteric ischemia, aortic catastrophe, portal vein thrombosis, and Fitz-Hugh-Curtis syndrome. Identifying the origin of patients’ pain can be difficult, as abdominal pain can have components of visceral and parietal pain, as well as referred. Visceral pain is experienced secondary to stretching of unmyelinated fibers innervating the walls or capsules of organs and follows a segmental distribution relating to the embryologic origin of the organ. It is usually midline secondary to the bilateral innervation. This pain is usually described as cramp-like or achy. Irritation of the parietal peritoneum is responsible for parietal pain which localizes to the corresponding dermatome superficial to the affected organ. Referred pain is pain appreciated at a site distant to the source. The patterns of referred pain are secondary to embryological development. Referred pain is usually located on the same side as the involved organ.

Articles of Interest

Biliary colic and complications from gallstones

Gallstones are common among the general population, but because they rarely cause symptoms many people are unaware of their presence. Over a ten-year period, approximately one-third of people with gallstones will develop the painful symptoms of biliary colic. This can be a precursor to more serious conditions, such as acute cholecystitis and pancreatitis that require acute advanced endoscopic or surgical assessment. The presence of upper abdominal pain, despite normal physical examination and blood test results, is consistent with uncomplicated biliary colic. An ultrasound should be arranged for all patients with features suggestive of biliary colic to confirm a diagnosis. Patients with biliary colic are generally managed in the community with non-steroidal anti-inflammatory drugs (NSAIDs) and lifestyle advice while awaiting assessment for laproscopic cholecystectomy.

Biliary pain, no gallstones—remove the gallbladder, anyway?

Family physicians often are the first to evaluate patients with recurrent biliary colic. Biliary colic without gallstones—also known as BD or acalculous cholecystitis—is a functional disorder of the gallbladder or bile duct. Approximately 8% of men and 21% of women with biliary pain do not have gallstones. BD has been successfully treated with cholecystectomy.

Gallstones: Why are doctors so poor at recognising biliary colic?

There seems to be little consensus on the definition of biliary colic amongst doctors, but the commonly held belief that the pain is “colicky”, always in the right upper quadrant and associated with fatty meals, is not an accurate representation of what most patients experience

How Should Biliary Colic Without Stone Be Treated?

The authors conclude that acalculous cholecystitis is probably a heterogeneous group of conditions, but that 96 percent of patients reported at least satisfactory relief of symptoms following laparoscopic cholecystectomy. They point out the 11 percent false-negative rate for gallstones based on surgical findings after a negative scan.

Is biliary colic dangerous?

Biliary colic (intermittent bile duct obstruction): sudden and rapidly increasing pain (severe pain or tenderness) in the right upper abdomen or epigastrium; some people have pain that radiates to the right shoulder (or back pain at the top of the scapula) and/or causes nausea and vomiting. The pain usually subsides in about 1 to 5 hours although mild pain can last about a day.

The Gallstone Groans

An episode of ‘biliary colic’, as we refer to it, is most likely to develop after eating when the gallbladder is actively contracting. It often feels like sharp or band-like pain in the upper abdomen (typically worse on the right side, where the gallbladder is located), but can sometimes feel more like pain in the chest, back, or even the right shoulder. It is common to also experience nausea and vomiting along with the pain. Most times, the pain eventually resolves when the gallbladder calms down or the stones passes into the intestine, however, the length of an episode can be highly variable.

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Harvard Health

A person with biliary colic usually complains of an ache or a feeling of pressure in the upper abdomen. This pain can be in the center of the upper abdomen just below the breastbone, or in the upper right part of the abdomen near the gallbladder and liver. In some people, the abdominal pain spreads back toward the right shoulder blade. Many people also have nausea and vomiting.

SAEM

Patients with uncomplicated biliary colic can follow up in clinic with symptomatic control and dietary modification.