Biliary colic is often related to gall bladder stones
|Classification and external resources|
Biliary colic is the term used to describe a type of pain related to the gallbladder that occurs when a gallstone transiently obstructs the cystic duct and the gallbladder contracts. Cholelithiasis refers to the presence of gallstones and cholecystitis to the inflammation associated with irritation of the viscera secondary to obstruction of the cystic duct by gallstones.
Pathophysiologically, gallstone formation occurs from the precipitation of crystals that aggregate to form macroscopic stones. The most common form is cholesterol gallstones. Other forms include calcium, bilirubin, pigment and mixed gallstones.
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, retrosternal. 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. 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. Pancreatitis should be considered if the lipase value is elevated; gallstone disease is the major cause of pancreatitis.
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.
Cholesterol gallstone formation risk factors include age, female sex, family history, race (e.g. higher incidence in aboriginals), pregnancy, parity, obesity, oral contraceptives, diabetes mellitus, cirrhosis, prolonged fasting, rapid weight loss, total parenteral nutrition, ileal disease and impaired gallbladder emptying.
Patients that have gallstones and biliary colic are at increased risk for complications including cholecystitis. 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.
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. Further signs on ultrasound may suggest cholecystitis or choledocholithiasis. Computed Topography (CT) is not indicated when investigating for gallbladder disease as 60% of stones are not radiopaque. CT should only be utilized if other intraabdominal pathology exists or the diagnosis is uncertain. Endoscopic retrograde cholangiopancreatography (ERCP) should be used only if lab tests suggest the existence of a gallstone in the bile duct. ERCP is then both diagnostic and therapeutic.
Relief of symptoms is the initial management of symptoms. These include correcting electrolyte and fluid imbalance that may occur with vomiting. Antiemetics, such as dimenhydrinate, also known as gravol, are used to treat the nausea. Pain is usually corrected with anti-inflammatories, NSAIDs such as ketorolac and diclofenac; or in the acute setting, narcotics, such as morphine, less commonly may be used. NSAIDs are more or less equivalent to opioids (narcotics).
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. Early laparoscopic cholescystectomy happens within 72 hours of diagnosis. 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. 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.
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).
Complications from delayed surgery include pancreatitis, empyema (collection of pus) or perforation of the gallbladder, cholecystitis, cholangitis, and obstructive jaundice.
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