Biliary colic

Biliary colic, also known as a gallbladder attack, is when pain occurs due to a gallstone temporarily blocking the bile duct.^[1] Typically the pain is in the right upper part of the abdomen and it can radiate to the shoulder.^[2] Pain usually lasts from one to a few hours.^[1] Often it occurs after eating a heavy meal or during the night.^[1] Repeated attacks are common.^[3]

Gallstone formation occurs from the precipitation of crystals that aggregate to form stones. The most common form is cholesterol gallstones.^[4] Other forms include calcium, bilirubin, pigment and mixed gallstones.^[4] Other conditions that produce similar symptoms include appendicitis, stomach ulcers, pancreatitis, and gastroesophageal reflux disease.^[1]

Treatment for gallbladder attacks is typically surgery to remove the gallbladder.^[1] This can be either done through several small incisions or through a single larger incision.^[1] Surgery is typically done under general anesthesia.^[1] In those who are unable to have surgery, medication to try to dissolve the stones or shock wave lithotripsy may be tried.^[1]

In the developed world 10-15% of adults have gallstones.^[3] Of those with gallstones, biliary colic occurs in 1-4% each year.^[3] Nearly 30% of people have further problems related to gallstones in the year following an attack.^[3] About 15% of people with biliary colic eventually develop inflammation of the gallbladder if not treated.^[3] Other complications include inflammation of the pancreas.^[3]

Signs and symptoms

Pain is the most common presenting symptom. It is usually described as sharp right upper quadrant pain that radiates to the right shoulder, or less commonly, behind the breastbone.^[5] Nausea and vomiting can be associated with biliary colic. Individuals may also present with pain that is induced following a fatty meal and the symptom of indigestion. The pain often lasts longer than 30 minutes, up to a few hours.^[5] Patients usually have normal vital signs with biliary colic whereas patients with cholecystitis are usually febrile and more ill appearing. Lab studies that should be ordered include a complete blood count, liver function tests and lipase. In biliary colic lab findings are usually within normal limits. Alanine aminotransferase and aspartate transaminase are usually suggestive of liver disease whereas elevation of bilirubin and alkaline phosphatase suggests common bile duct obstruction.^[6] Pancreatitis should be considered if the lipase value is elevated; gallstone disease is the major cause of pancreatitis.

Causes

Biliary pain is most frequently caused by obstruction of the common bile duct or the cystic duct by a gallstone. However, the presence of gallstones is a frequent incidental finding and does not always necessitate treatment, in the absence of identifiable disease. Furthermore, biliary pain may be associated with functional disorders of the biliary tract, so called acalculous biliary pain (pain without stones), and can even be found in patients post-cholecystectomy (removal of the gallbladder), possibly as a consequence of dysfunction of the biliary tree and the sphincter of Oddi. Acute episodes of biliary pain may be induced or exacerbated by certain foods, most commonly those high in fat.^[7]

Risk factors

Cholesterol gallstone formation risk factors include age, female sex, family history, race (e.g. higher incidence in aboriginals),^[5] pregnancy, parity, obesity, birth control, diabetes mellitus, cirrhosis, prolonged fasting, rapid weight loss, total parenteral nutrition, ileal disease and impaired gallbladder emptying.^[8]

Patients that have gallstones and biliary colic are at increased risk for complications including cholecystitis.^[9] Complications from gallstone disease is 0.3% per year and therefore prophylactic cholecystectomy are rarely indicated unless part of a special population that includes porcelain gallbladder, individuals eligible for organ transplant, diabetics and those with sickle cell anemia.^[5]

Diagnosis

Diagnosis is guided by the person's presenting symptoms and laboratory findings. The gold standard imaging modality for the presence of gallstones is ultrasound of the right upper quadrant. There are many reasons for this choice including no exposure to radiation, low cost, and availability in city, urban and rural hospitals. Gallstones are detected with a specificity and sensitivity of greater than 95% with ultrasound.^[10] Further signs on ultrasound may suggest cholecystitis or choledocholithiasis.^[11] Computed Topography (CT) is not indicated when investigating for gallbladder disease as 60% of stones are not radiopaque.^[11] CT should only be utilized if other intraabdominal pathology exists or the diagnosis is uncertain.^[12] Endoscopic retrograde cholangiopancreatography (ERCP) should be used only if lab tests suggest the existence of a gallstone in the bile duct.^[11] ERCP is then both diagnostic and therapeutic.

Management

Medications

Initial management includes the relief of symptoms and correcting electrolyte and fluid imbalance that may occur with vomiting.^[6] Antiemetics, such as dimenhydrinate, are used to treat the nausea.^[6] Pain may be treated with anti-inflammatories, NSAIDs such as ketorolac or diclofenac.^[13] Opioids, such as morphine, less commonly may be used.^[14] NSAIDs are more or less equivalent to opioids.^[15]

In biliary colic, infection is not a concern, as this would result in cholecystitis, and therefore antibiotics are not required.^[16]

Surgery

Treatment is dictated by the underlying cause. The presence of gallstones, usually visualized by ultrasound, generally necessitates a surgical treatment (removal of the gall bladder, typically via laparoscopy). Removal of the gallbladder with surgery, known as a cholecystectomy, is the definitive treatment for biliary colic. Tentative evidence suggest that early gallbladder removal may be better than delayed removal.^[17] Early laparoscopic cholescystectomy happens within 72 hours of diagnosis.^[11] In a Cochrane review that evaluated receiving early versus delayed surgery, they found that 23% of patients who waited on average 4 months ended up in hospital for complications, compared to no patients with early intervention with surgery.^[11][17] Early intervention has other advantages including reduced number of visits to the emergency department, less conversions to an open surgery, less operating time required, and reduced time in hospital post operatively.^[11]

Complications

The presence of gallstones can lead to inflammation of the gall bladder (cholecystitis) or the biliary tree (cholangitis) or acute inflammation of the pancreas (pancreatitis). Rarely, a gallstone can become impacted in the ileocecal valve that joins the caecum and the ileum, causing gallstone ileus (mechanical ileus).^[5]

Complications from delayed surgery include pancreatitis, empyema (collection of pus) or perforation of the gallbladder, cholecystitis, cholangitis, and obstructive jaundice.^[11]

Biliary pain in the absence of gallstones, known as postcholecystectomy syndrome, may severely impact the patient's quality of life, even in the absence of disease progression.^[18]

Epidemiology

The annual risk of developing biliary colic is 2 to 3%.^[5][9]

References

External links

• Diagram of pain radiation