Definition: pain caused by symptomatic gallstones
Aetiology/ risk factors:
-Gallstones are symptomatic with biliary colic if they cause cystic duct obstruction or are passed into the common bile duct.
R/F for gallstones: Female, Fat, Forty, Fertile (do not say this to a patient!)
Also-parenteral nutrition, drugs (OCP, octreotide), FHx, interruption of enterohepatic circulation of bile salts (e.g. Crohn’s disease), terminal ileal resection. Pigment stones: haemolytic disorders (e.g. Sickle cell), liver cirrhosis
R/F for stones becoming symptomatic: smoking, parity (previously carried pregnancies to viable gestational age).
-Gallstones very common- prevalence = 8% of those over 40 years. 90% remain asymptomatic.
-3 x more females in younger population but equal sex ration after 65 years
~ 50,000 cholecystectomies (GB removals) performed in UK per year
-Sudden onset, severe right upper quadrant pain
-Pain is constant in nature
-Pain may be epigastric
-Pain may radiate to the back
-Pain may radiate to the right scapula
-Often precipitated by a fatty meal
-Increases in intensity and lasts for several hours
-May be associated with nausea & vomiting
-Unlike cholecystitis and cholangitis, patients do not present with fever
-RUQ or epigastric tenderness
-may be jaundiced (i.e. if blocking flow of bile in the common bile duct)- but more often not
FBC- WCC normal, distinguishing biliary colic from cholecystitis and cholangitis
LFTs- may show obstructive jaundice picture = ↑bilirubin, ↑alkaline phosphatase (but this is more likely in cholangitis, and LFTs usually normal in simple biliary colic)
Amylase- risk of pancreatitis/ distinguish from pancreatitis as biliary colic can also be epigastric and may radiate to the back
–Ultrasound– may show gallstones in gallbladder and biliary duct, and dilation of biliary tree indicative of obstruction. USS is more sensitive to stones in the gallbladder than in the ducts. (Common bile duct dilatation if > 6cm)
-Consider ERCP/MRCP- visualise biliary tree e.g. if doubt about diagnosis
-Exclude other disease: urinalysis, CXR, ECG
-For mild symptoms: avoidance of fat in diet.
-If severe, admission with:
-Analgesia (e.g. pethidine or morphine)
-Antibiotics, if signs of infection
–If symptoms fail to improve, suspect a localised abscess or empyema. This can be drained percutaneously.
-Elective cholecystectomy is the definitive management to prevent further biliary colic.
-Acute and chronic cholecystitis
-Mucocoele, empyema (gallbladder full of mucus, pus)
-Carcinoma in biliary tract
-Gallstone ileus (gallstone in gut)
–Mirizzi’s syndrome: common hepatic/bile duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct or Hartmann’s pouch of the gallbladder
Post-cholecystectomy- bleeding, infection, bile leak, bile duct injury, post-cholecystectomy syndrome (persistent dyspeptic syndrome), hernias.
Prognosis: surgery is an effective treatment for symptomatic gallstones