Biliary colic
| Biliary colic | |
| ICD-9 | 574.20 |
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| DiseasesDB | 2533 |
| eMedicine | med/224 |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Assistant Editor-in-Chief: Soumya Sachdeva, Prashanth Saddala M.B.B.S
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Overview
Biliary colic is pain associated with irritation of the viscera secondary to cholecystitis and gallstones. Unlike renal colic, the phrase 'biliary colic' refers to the actual cholelithiasis.
Pain is accompanied with biliary colic, though unlike renal colic, the phrase 'biliary colic' refers to the actual cholelithiasis. Although it is frequently described as a colic, the pain is steady, starts rapidly and lasts at least 30 minutes and up to several hours. Many patients complain of right upper quadrant pain, rt flank pain, or even mid chest pain with cholelithiasis. There may be irradiation to the back and shoulders and other concomitant symptoms such as vomiting and diarrhea. Fatty foods can provoke biliary pain, but this association is relatively non-specific.
Biliary pain can be associated with objective findings (dilation of the biliary tract, elevation of plasma liver enzyme concentration, elevation of bilirubin, gamma-GT and alkaline phosphatase).
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, 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.
Risk factors
- More common in females.
- Obesity
- Common amongst Pima Indians, North Americans and Chileans.
- Generally Japanese have the lowest incidence of stones.
- Sudden weight loss
- Prolonged fasting.
- Pregnancy
- Presence of Crohn's disease.
- Cystic fibrosis
- Diabetes,
- Liver cirrhosis
- Increasing age
- Extensive bowel resection
- Use of contraceptives and other medications like largactil, octreotide, and clofibrate
Differential Diagnosis
- Amoebic liver abscess
- Perforated peptic ulcer
- Upper small bowel obstruction.
Natural history, Complications and Prognosis
Complications
The more serious complication is total blockage of the bile duct which leads to jaundice, which if it is not corrected naturally or by a surgical procedure can be fatal as it causes liver damage.
The presence of gallstones can lead to infection of the gall bladder (cholecystitis) or the biliary tree (cholangitis) or acute inflammation of the pancreas (pancreatitis). Rarely, an impacted gallstone can obstruct the bowel, causing gallstone ileus (mechanical ileus).
Biliary pain in the absence of gallstones may severely impact the patient's quality of life, even in the absence of disease progression.
Diagnosis
History and Symptoms
This condition causes crescendos of severe pain in the right upper abdomen and sometimes through to the upper back and/or right shoulder. The pain relates to the obstruction of the passage of bile and can be associated with eating fatty foods. There is usually an inflammatory component to the pain as the characteristic colic is not completely relieved between crescendos.
Other symptoms are nausea and vomiting, diarrhea, bleeding caused by continuous vomiting, and dehydration caused by the nausea and diarrhea.
Treatment
Pain management is an important part of treating biliary colic. Treatment is often with NSAIDs such as ketorolac (Toradol) and diclofenac (Voltaren). Hyoscine butylbromide (Buscopan) is occasionally used but is less effective than analgesics.[1]
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) but may also respond in some cases to medications (ursodeoxycholic acid) or lithotripsy.