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Biliary Colic

Biliary colic is a symptom of cystic duct obstruction due to the passage of gallstones or gallbladder sludge. This is not generally associated with inflammatory reactions.


Presentation

Biliary colic has a sudden onset and may persist for more than 3 hours. Pain may often radiate to the suprascapular region [4]. Pain originates in the epigastric area or the right upper quadrant and generally last for about 30 minutes. Biliary colic is not affected by position of the body, defaecation or movement. Vomiting and nausea are also associated with the pain. Episodes are often found to be more common during the night, particularly after a fatty meal. After the initial episode of pain, it may recur within hours. In some rare cases, recurrence is seen after years of first episode. Some of the uncommon symptoms of the condition include chest pain, belching, dyspepsia, and non-specific abdominal pain.
Pain associated with choledocholithiasis is similar to that of biliary colic, but can be distinguished by the presence of obstructive jaundice, cholangitis, or acute pancreatitis [5]. Differential diagnosis include gastroesophageal reflux disease (GERD), peptic ulcer disease, appendicitis, non-ulcer dyspepsia, hepatitis and nephrolithiasis.

Severe Pain
  • In this study NSAIDs were the most effective analgesia for patients with severe pain.[ncbi.nlm.nih.gov]
  • For moderate pain, codeine and paracetamol are suggested, and for severe pain opioids are useful. Antispasmodic medications including hyoscine butylbromide, may be used in some patients with biliary colic.[symptoma.com]
  • In this double-blind placebo-controlled experiment, 60 subjects with moderate to severe pain caused by biliary colic were injected with ceruletide, 1 ng/kg iv or with an equal volume of saline solution.[ncbi.nlm.nih.gov]
  • She returned within a week with worsening liver enzymes, severe pain, and vomiting. A hepatobiliary iminodiacetic acid (HIDA) scan was done, which again did not show the gall bladder.[ncbi.nlm.nih.gov]
  • Biliary colic is a sudden attack of severe pain that arises in the upper middle or right upper abdomen near the rib cage, often radiating to the back or shoulder.[healthitalk.com]
Intravenous Administration
  • During saline intravenous administration, increasing biliary tree pressure resulted in pain in 5 patients, with the threshold for pain being 40 cmH2O.[ncbi.nlm.nih.gov]
  • The specificity of the test can be improved by intravenous administration of morphine, known as morphine cholescintigraphy, which induces spasm of this sphincter, thus increasing back pressure to fill the gallbladder. [18] Abdominal Radiography The advantages[emedicine.com]
Camping
  • In the trial by Camp and colleagues ( Camp 1992 ), some mild adverse events were reported.[doi.org]
Nightmare
  • For patients with medical insurance, the nightmare is easily ended by having the gall bladder removed through a laparosope, often without even spending a night in the hospital.[hypochondriacheaven.com]
Colic
  • Biliary colic is a symptom of cystic duct obstruction due to the passage of gallstones or gallbladder sludge. This is not generally associated with inflammatory reactions. Biliary colic has a sudden onset and may persist for more than 3 hours.[symptoma.com]
  • BACKGROUND: Although non-steroidal anti-inflammatory drugs (NSAID) and spasmolytics have been used to relieve biliary colic, the role of these drugs in the natural history of biliary colic has not been clarified.[ncbi.nlm.nih.gov]
  • In biliary colic, lab findings are usually within normal limits.[en.wikipedia.org]
  • Patients who had episodes of biliary colic prior to the biliary colic that necessitated surgical referral and those who had biliary colic for the first time.[doi.org]
  • INTRODUCTION: Cholecystectomy in cases of "warning" episodes of biliary colic may prevent biliary pancreatitis.[ncbi.nlm.nih.gov]
Abdominal Pain
  • The chronobiological and other features of biliary pain reported here should be useful in the diagnostic evaluation of abdominal pain.[ncbi.nlm.nih.gov]
  • During the next three years the patient complained both of mild abdominal pain, probably biliary colic, and mild effort related angina pectoris without a relation between the two symptoms.[ncbi.nlm.nih.gov]
  • A 78-year-old male patient was admitted to our Emergency Department (ED) due to acute abdominal pain.[ncbi.nlm.nih.gov]
  • Symptoms A) Abdominal Pain characteristics 1) Right Upper Quadrant Abdominal Pain or Epigastric Abdominal Pain 2) Dull visceral ache 3) Poorly localized discomfort 4) Pain radiates to right posterior shoulder or scapula B) Abdominal Pain timing: 2. 1)[slideshare.net]
Epigastric Pain
  • We describe a case showing rapid fluctuations in common bile duct diameter during 72 hours in a patient presenting with epigastric pain and vomiting.[ncbi.nlm.nih.gov]
  • Misdiagnosis is frequent with potential disastrous implications, especially with other causes of epigastric pain (atypical myocardial ischemia, perforated ulcer, etc.).[ncbi.nlm.nih.gov]
  • pain, sometimes felt on the right No fever, may have tachycardia if pain is bad tender over gallbladder if it is distended Constant sharp/stabbing pain in right upper quadrant may radiate to Rt shoulder/back Fever, tachycardia Tenderness in right upper[jjs.me.uk]
  • I will go out on a limb and state that it is still common for patients to present with epigastric pain that was previously diagnosed by the primary care physician or one of my colleagues in the ED as gastritis or “abdo pain NYD” and turns out to be biliary[edeblog.com]
  • The most common cause is cystic duct obstruction by gallstone(s), and the initial symptom may be epigastric pain. A pain-free interval may occur before symptoms shift to the right upper quadrant. Older patients may have only localized tenderness.[aafp.org]
Severe Abdominal Pain
  • When To Call a Professional Call your doctor whenever you have severe abdominal pain, with or without nausea and vomiting.[drugs.com]
  • Cholecystitis - usually with this type you will have severe abdominal pain so the physician will usually prescribe antibiotics and fluids If antibiotics do clear up the problem then you would have to have gallbladder surgery.[hubpages.com]
  • Even qualified doctors can't diagnose over the internet, so do bear that in mind when seeking or giving advice. snozzlemaid Sun 14-Jul-13 19:59:56 Had an episode of severe abdominal pain this afternoon. It came on fairly quickly - about 10 mins.[mumsnet.com]
Tenderness in the Right Upper Quadrant
  • Rebound tenderness in the right upper quadrant is also characteristic of acute cholecystitis. Routine tests for biliary colic include complete blood count, liver function test, serum creatinine, CRP, serum amylase, and urine dipstick.[symptoma.com]
  • […] in the right upper quadrant, as well as one of the systemic signs of inflammation, such as fever, elevated white blood cell (WBC) count, and elevated C-reactive protein level, are diagnosed as having acute cholecystitis. [22] Imaging findings characteristic[emedicine.com]
  • Acute cholecystitis Acute cholecystitis presents with severe pain associated with a raised temperature, tachycardia, tenderness in the right upper quadrant (especially on inspiration) and occasionally, positive blood cultures.[racgp.org.au]
Heart Block
  • Biliary colic can cause severe reversible reflex bradycardia (Cope's Sign), even complete heart block. Pain relief is very important in the management of such cases.[ncbi.nlm.nih.gov]
Eruptions
  • Considerations Although specific foods can trigger biliary colic, any meal could cause your symptoms to erupt. Food you can tolerate on one day may cause problems on another.[livestrong.com]
Impulsivity
  • Spasmolytic drugs such as hyoscine butylbromide (also known as scopolamine) inhibit the action of acetylcholine and stop the transmission of parasympathetic nerve impulses, thus lessening the spasms of the smooth muscle in the gastrointestinal tract and[doi.org]
Neglect
  • Each and every attack must be reported to the doctor and must not be neglected even if the pain withdraws spontaneously. The doctor must rule out the presence of certain complications and suggest most suitable treatment modality.[ic.steadyhealth.com]

Workup

Pain in the right upper quadrant on physical examination is the most common, confirming diagnostic feature of biliary colic. Pain may be ongoing and severe. Rebound tenderness in the right upper quadrant is also characteristic of acute cholecystitis. Routine tests for biliary colic include complete blood count, liver function test, serum creatinine, CRP, serum amylase, and urine dipstick. In the absence of any complications, complete blood count, liver function test and serum amylase remain normal in biliary colic. Elevated CRP and leukocytosis are seen in patients with cholecystitis. Liver enzymes are elevated in choledocholithiasis. Serum amylase may be increased in patients with severe pancreatitis. Aspartate aminotransferase levels may increase with the passage of bile duct stone.

Abdominal ultrasound is used to confirm the diagnosis of biliary colic pain [6]. This is often suggested for patients with significant, persistent or recurrent upper quadrant pain. Abdominal ultrasound is useful in detecting gallstones in approximately 95% of the cases. It may also be helpful in detecting biliary sludge in most. MRI may be used to detect gallstones in patients with choledocholithiasis [7]. Endoscopic retrograde cholangiopancreatography (ERCP) is used to diagnose and treat common bile duct stones [8].

Electrocardiogram Change
  • During the next three weeks attacks of epigastric and right hypochondrial pain preceded by crushing chest pain with identical electrocardiogram changes occurred with decreasing frequency.[ncbi.nlm.nih.gov]

Treatment

Biliary colic is usually managed by with analgesics. Multiple analgesics may be given for patients with severe pain [9]. Intramuscular diclofenac is used to prevent progression to acute cholecystitis [10]. Diclofenac is also indicated for rapid onset of biliary colic. Those who are unable to tolerate oral or intramuscular route may be recommended diclofenac suppositories. For moderate pain, codeine and paracetamol are suggested, and for severe pain opioids are useful. Antispasmodic medications including hyoscine butylbromide, may be used in some patients with biliary colic. Some patients may require antiemetic, as nausea is a common symptom.

The standard therapy is elective cholecystectomy. Laparoscopic cholecystectomy is the preferred choice to prevent future episodes of biliary colic. This is particularly useful in patients with acute cholecystitis. Patients who are unable to undergo surgery can opt for percutaneous drainage of bile duct followed by antibiotics. Lithotripsy is a method in which acoustic shock waves are used to break gallstones which can then pass through bile duct into duodenum. Oral bile acids are given along with this method.

Prognosis

When left untreated, biliary colic may recur in 50% of the patients. It may lead to complications at the rate of 2% per year. Those who are under medical therapy for treating biliary colic may see recurrence at the rate of 10%. Biliary colic may not recur after cholecystectomy

Etiology

Gallstone disease is the most common etiological factor of biliary colic. Biliary parasites, infectious agents, tumors, and blood clots may also cause this symptom. The pain results from the distention of the biliary tree. About 70% of the gallstones are formed of cholesterol [2]. Biliary pain may also occur without gallstones, and is referred to as acalculous biliary pain. Functional abnormalities in the biliary tree and sphincter of Oddi may also result in this symptom. Some patients may get biliary colic post-cholecystectomy. Certain foods, particularly those high in fat, are also capable of aggravating biliary pain.

Factors that increase the risk of gallstone disease, increase the risk of biliary colic. This includes body weight, female gender, certain medications like oral contraceptives and fibrates, family history, rapid weight loss, and hemolytic disorders. Rapid weight loss is associated with gallstones, which after a period of time become symptomatic.

Epidemiology

Biliary colic is a very common condition in patients with gallstones. Incidence of biliary colic in these patients is reported to be 2000 per 100,000 [3]. About 30% of the patients experience this pain only once. In most of the cases, the upper abdominal pain and gallstones are undiagnosed and hence the exact prevalence of the condition is difficult to determine.

Prevalence of biliary colic increases with age, and is about 30% in females aged 60-70 years. The prevalence in females in the age group of 20-30 years is just 5%. In males the prevalence in the age group of 60-70 years is about 10%. In general, the male to female ratio of prevalence is 1:2. Prevalence of biliary colic is also found to vary among different ethnic groups. The rate is very high among Pima Indians of south western United States and Amerindians of Chile.

Sex distribution
Age distribution

Pathophysiology

Biliary colic is usually caused by gall stone/s passing into or through cystic duct. The movement causes the distention of the cystic duct wall. Continued impaction of the gallstone in the duct results in inflammation and acute cholecystitis. Biliary colic occurs more often in the night because of the position of the gallbladder. As the person is in bed, the gallbladder is in horizontal position. Thus gallstones instead of falling to the bottom of the fundus, tend to remain near the opening of the cystic duct.

Meal rich in fatty foods, particularly in the evening, results in excess secretion of bile which fill the gallbladder. And as digestion proceeds, flow of bile pushes stones from the gallbladder into the duct, resulting in biliary colic in the night. Colic may cease once the stone enters the common bile duct or duodenum. Pain depends on the difficulty in traversing the duct. Biliary colic often has a sudden onset and is often severe in intensity.

About 70% of the gallstones are formed of cholesterol. Microcrystals of cholesterol may precipitate in biliary sludge in the gallbladder. Gallstones may also be formed of calcium bilirubinate, produced by increased bilirubin content or cirrhosis.

Prevention

Dietary modification is the best way to deter the occurrence of biliary colic. Decreased fat intake is the preferred change in diet. Increasing physical activity, maintaining a normal body weight, and including more of fiber in the diet also are important in controlling gallstones. Those who are at a high risk of developing complications may opt for prophylactic cholecystectomy.

Summary

Biliary colic is a symptom of cystic duct obstruction due to the passage of gallstones or gallbladder sludge [1]. This is not generally associated with inflammatory reactions. About 1 to 2% of the patients with asymptomatic gallstones develop this pain after a period of time. In majority of patients, biliary colic is a precursor to cholecystitis or other complications associated with gallstones. The term ‘biliary colic’ is considered to be a misnomer, as the pain is steady and not transient. This symptom of gallstones is more often seen during the night, possibly because of the position of the gallbladder. Once the stone reaches the common bile duct or the duodenum, the colic may cease. Biliary colic has a sudden onset and is usually severe. It is generally treated with non-steroidal anti-inflammatory drugs (NSAIDs) and lifestyle changes.

Patient Information

Biliary colic is the most common symptom of gallstone disease. Over a period of time, most of the patients with gallstones develop this pain. It can be a precursor of more serious conditions like pancreatitis and acute cholecystitis. It is found at the rate of 2000 in 100,000 patients with gallstones. Biliary colic is caused by the passage of gallstones through the cystic duct. It often has a sudden onset and may be severe. Pain is associated with the distention of the duct.

Biliary colic is more common during the night than day. This may be because of the upright position of the gallbladder when a person is standing. Any of the stones passing through the duct in this position may fall lower down into the duct. During night, as the patient is in bed, gallbladder is also in horizontal position and the stones may not move effortlessly through the duct. If the patient has a rich, fatty meal in the night, secretion of bile increases and fill the gallbladder. As digestion continues, the flow of bile may move the stone into the cystic duct. This may result in biliary colic. The pain may stop when the stone reaches the common bile duct or duodenum. Intensity of pain depend on how hard it is for the stone to move through the bile duct.

Unlike the name, biliary colic is a steady pain in the right upper quadrant. The onset of pain is sudden and may continue for some time. The duration of pain may be a maximum of 6 hours. The pain usually resolves within 24 hours. On physical examination the right upper quadrant of the patient may show tenderness. Confirmatory diagnosis of biliary colic is based on clinical manifestations and laboratory findings. Abdominal ultrasound is the most commonly used imaging technique for locating the presence of gall stones. This method helps to find gallstones accurately. It is also useful in identifying complications associated with gallstones. Endoscopic retrograde cholangiopancreatography may be suggested if stones are suspected in the bile duct. This is used both for diagnosis and treatment. Other routine tests like full blood count, liver function tests, serum creatinine levels, serum amylase levels and urine dipstick are also used in the diagnosis of biliary colic.

Patients presenting with biliary colic is sent for definitive diagnosis and surgical assessment while on pain killers. Life style management is the first step suggested for patients with uncomplicated biliary colic. Diet rich in fiber, and low in fat is helpful in improving the symptoms. Non-steroidal anti-inflammatory drugs (NSAIDS) are used to treat severe pain. When there is a rapid onset of pain, diclofenac injections may be suggested. For those presenting with moderate pain codeine and paracetamol are helpful. Opioids are used as an alternative to NSAIDS. Antispasmodic medications are given for some. Since nausea and vomiting are common features of biliary colic, antiemetics may be used. Elective cholecystectomy is used as the major surgical treatment of gallstones with biliary colic. This may be done laparoscopically or as an open surgery. Early intervention gives a good prognosis for patients with gallstones.

References

Article

  1. Auerbach, Paul S. Wilderness medicine. Philadelphia, PA: Elsevier/Mosby, 2012; 411–433.
  2. Cafasso DE, Smith RR. Symptomatic cholelithiasis and functional disorders of the biliary tract. Surg Clin North Am 2014;94:233–256.
  3. Ransohoff DF, Gracie WA. Treatment of gallstones. Ann Int Med. 1993;119:606-619. 
  4. Mackay S, Dillane P. Biliary pain. Aust Fam Physician 2004;33:977–81.
  5. National Institute for Health and Care Excellence (NICE). Single-incision laproscopic cholecystectomy. NICE, 2010. 
  6. Fischer JE, ed. Master of surgery 5th ed. Philadelphia, 2007 PA. Lippincott Williams & Wilkins.
  7. Caddy GR, Tham TCK. Gallstone disease: Symptoms, diagnosis and endoscopic management of common bile duct stones. Best Pract Res Clin Gastroenterol 2006;20:1085–101.
  8. Bencini L, Tommasi C, Manetti R, et al. Modern approach to cholecysto-choledocholithiasis. World J Gastrointest Endosc 2014;6:32–40.
  9. Colli A, Conte D, Valle SD, et al. Meta-analysis: nonsteroidal anti-inflammatory drugs in biliary colic. Aliment Pharmacol Ther 2012;35:1370–8.
  10. Akriviadis EA, Hatzigavriel M, Kapnias D, Kirimlidis J, Markantas A, Garyfallos A. Treatment of biliary colic with diclofenac: a randomized, double-blind, placebo-controlled study. Gastroenterology. 1997;113:225-231. 

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Last updated: 2019-07-11 22:13