AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

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Background

Biliary colic is a symptom of discomfort and is often not accompanied by any clinical signs. It represents one of the causes of epigastric pain. It is the most common presentation of symptomic gallstone disease (cholelithiasis/choledocholithiasis). Because this is a symptom, numerous other disease processes may result in pain that is similar to biliary colic, and, certainly, biliary colic is not the most common cause of epigastric pain. For this reason, other disease processes should be considered during the evaluation of patients being considered to have biliary colic.

Careful history and examination are cornerstones to making an accurate clinical diagnosis, essentially because of the high incidence of gallstones in the population and because most gallstones are asymptomatic. The potential disastrous implications of a misdiagnosis as biliary colic instead of alternative diagnoses that may present with epigastric pain (eg, atypical myocardial ischemia) cannot be overemphasized. Patients also can be particularly unhappy and frustrated when their pain is not resolved following cholecystectomy. The differential diagnosis section lists other important medical conditions one should consider in patients who present with possible biliary colic (see Differentials).

History should elicit the nature, intensity, location, duration, onset, cessation, associated factors, aggravating factors, relieving factors, radiation, and frequency (NILDOCARRF) of the pain (see History). The pain of biliary colic is listed inaccurately as a colic. This term implies a paroxysmal pain that waxes and wanes, when, in actuality, the pain of biliary colic is generally a constant and slowly progressive pain. The pain generally follows a meal and may wake up a person several hours later. In fact, pain immediately with a meal is not characteristic of biliary colic.

It is important while taking the history that one evaluates the risk factors for stone formation, addresses and excludes other potential causes for the pain, and concurrently evaluates medical comorbidities that may influence management (eg, cardiovascular disease).

This visceral pain is believed to result from impaction of a gallstone in the cystic duct and/or ampulla of Vater. The resulting impaction causes distension of the gallbladder and/or biliary tract, and this distension activates visceral afferent sensory neurons. The resultant pain is commonly localized poorly and general refers midline to the representative dermatomes T8/9 (mid epigastrium, right upper quadrant), although it may radiate to the right upper quadrant. Localized pain or persistent pain generally represents a complication of cholelithiasis or choledocholithiasis (eg, cholecystitis, cholangitis, pancreatitis).

Biliary colic is the presenting symptom in 80% of patients with gallstone disease who seek medical care; however, only 10-20% of all individuals with gallstones experience severe gallstone pain. The risk of developing biliary pain or stone-related complications in asymptomatic patients is low, at 1-2% per year. For this reason, clinical practice favors treatment of only symptomatic disease, with the exception of a few unique circumstances. Two thirds of patients presenting with their first attack of biliary colic have recurrent pain within 2 years.

Pathophysiology

A gallstone produces visceral pain by obstructing the cystic duct or ampulla of Vater, resulting in distention of the gallbladder or biliary tree. Pain is relieved when the gallstone migrates back into the gallbladder, passes through the ampulla, or falls back into the common bile duct (CBD). The pain of biliary colic may accompany sphincter of Oddi spasm.

Frequency

United States

Asymptomatic individuals with gallstones develop pain at an annual rate of 1-4%, with approximately 10% of individuals developing symptoms in 10 years and 20% developing symptoms in 20 years.

International

Limited international data appear to support a similar incidence of biliary colic in all populations with gallstones. The incidence of gallstones is greater in some races and cultures than in others.

Mortality/Morbidity

By definition, uncomplicated gallstone disease is not associated with signs or symptoms of systemic disease such as fever, jaundice, or leukocytosis. Patients with uncomplicated gallstone disease experience self-limited pain. Presentation is associated with only limited morbidity and never mortality, despite some patients' perception of the severity of pain and its significance. The frequency of progression to acute cholecystitis is 10-30%. Ibuprofen use possibly may decrease the likelihood of progression.

Race

In the United States, the prevalence of gallstone disease is highest among Hispanic Americans and Native Americans, especially the Pima Indians of Arizona, with 75% of women developing cholesterol gallstones by early adulthood.

Sex

Biliary colic is more common in women than in men, primarily related to the 2- to 3-fold increased incidence of cholelithiasis in women.

Age

The incidence of biliary colic depends on the incidence of gallstones. For this reason, the condition is rare in patients younger than 20 years and increases with age, occurring in approximately 2-4% of men older than 60 years and approximately 3-8% of age-matched women.

CLINICAL

Section 3 of 11  

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History

Note that, in general, there is no clear association between the presence of gallstones and upper abdominal pain (Jorgensen, 1989).

• Abdominal pain
• • Biliary colic usually starts abruptly and reaches maximum intensity within 60 minutes in two thirds of patients.
  • The pain generally continues without fluctuation and resolves gradually over 2-6 hours. Pain lasting longer than 6 hours should raise the suspicion for acute cholecystitis.
• NILDOCARRF
• • Nature: Many persons with this condition have difficulty describing the nature of the pain. It is a vague aching/cramping discomfort and generally is not sharp. The pain is constant rather than colicky; however, some interindividual variability exists.
  • Intensity: Among individuals, intensity is quite variable; however, the pain may be severe. Prolonged severe pain should raise concern that another etiology may be present.
  • Location: The epigastrium is the most common site, followed by the right upper quadrant; however, it may be located in many different sites within the abdomen. The pain tends to recur at the same sites. Infrequently (7%), pain may be represented in a retrosternal location.
  • Duration: The pain lasts from 30 minutes to 6 hours.
  • Onset: Progressive in onset, it reaches peak intensity within 30-60 minutes.
  • Cessation: Gradual persistent pain increases the likelihood of another etiology for the pain, including other complications of gallstones.
  • Associated factors: This condition may be associated with nausea, vomiting, or diaphoresis. Patients often cannot get comfortable. Patients generally do not have a fever.
  • Aggravating factors: Pain often follows a few hours after meals and may occur at night and wake the patient from sleep. Pain traditionally does not occur with meals or very soon after. Morphine has been noted to increase the pain in some people with biliary colic secondary to sphincter of Oddi dysfunction (SOD).
  • Relieving factors: Narcotic analgesia, nonsteroidal anti-inflammatory drugs (NSAIDs), and nitrates help relieve the pain.
  • Radiation: Pain may radiate to the right upper quadrant and to the back, following the subcostal margin. Other less common sites include retrosternal areas and the left upper quadrant. Isolated left arm (cardiac) and sharp right shoulder tip pain (cholangitis) should prompt consideration of alternative diagnoses.
  • Frequency: If the patient has had a previous attack, the likelihood of recurrence is higher. Fatty meals inconsistently elicit the pain, and nocturnal occurrence of pain is not infrequent. Repeat bouts in the same day may herald other complications.
• Uncomplicated biliary colic leaves no persisting symptoms following the acute attack.
• Finally, in relation to the acalculus patient with a question of biliary pain, the ROME II diagnostic criteria were published to help evaluate the patient considered to have gallbladder dysmotility. These criteria are listed below. Note that all criteria are pain related.
• • Episodes of severe steady pain located in the epigastrium and right upper quadrant
  • All of the following:
  • • Symptom episodes last 30 minutes or more, with pain-free intervals.
    • Symptoms have occurred on 1 or more occasions in the previous 12 months.
    • The pain is steady and interrupts daily activities or requires consultation with a physician.
    • There is no evidence of structural abnormalities to explain the symptoms.
    • There is abnormal gallbladder functioning with regard to emptying.

Physical

• Initial inspection often reveals an individual who is diaphoretic, pale, rolling about, and unable to get comfortable. Vomiting may accompany the pain.
• Examination may reveal some of the physical features associated with gallstone formation (eg, overweight, middle-aged, female).
• Occasionally, features of other conditions associated with an increased incidence of gallstones may be observed. This may extend to observing an individual with jaundice with stigmata of chronic liver disease. More often than not, physical findings are more important for excluding other causes for the pain.
• Patients with uncomplicated biliary colic do not have fever, chills, hypotension, or other signs of a significant systemic process.
• Sinus tachycardia is common during pain.
• Much interindividual variability exists when the pain is described; generally, it is at the milder end of the spectrum, although the pain may be excruciating for some individuals.
• Rebound, guarding, absent bowel sounds, or a palpable mass support an alternate diagnosis

Causes

The risk factors for cholelithiasis have been outlined in Cholelithiasis. A postulate explaining the greater nocturnal occurrence of biliary colic pain concerns the biliary anatomy. The horizontal lie of the gallbladder upon recumbency (sleeping) is believed to predispose patients to stone migration and subsequent impaction.

• Biliary dyskinesia and SOD present with a pain that often is consistent with biliary colic. These individuals often have undergone cholecystectomy without resolution of symptoms.
• Recurrent pain occurs in as many as 20% of people who have undergone cholecystectomy and is most common in those who have undergone cholecystectomy for acalculous disease or for atypical symptoms.
• Before allocating someone to the category of biliary dyskinesia/SOD, considering other causes of the symptoms described, particularly those outside the biliary system, is important. Investigations should focus on excluding retained stones in the biliary system. Treatment of SOD should take place at select institutions with extensive experience in this area. The investigation and treatment of this condition are beyond the scope of this article; however, a brief summary follows:
• • SOD is uncommon and accounts for 10% of people with postcholecystectomy abdominal pain in one series. It is a difficult diagnosis to establish and involves a combination of careful history, possibly some supportive laboratory tests, and cholangiography to exclude choledocholithiasis. Often, sphincter of Oddi manometry is performed.
  • Those most likely to respond to treatment by endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy are those with a history of classic biliary pain, abnormal liver enzymes in association with the pain, and delayed drainage post-ERCP.
  • Relief of pain after stenting the sphincter also is predictive of response to sphincterotomy.
  • Some trials have shown support for the use of nifedipine and nitrates in selected populations.

DIFFERENTIALS

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Other Problems to be Considered

Biliary dyskinesia
Sphincter of Oddi dysfunction
Spinal nerve root compression
Nonulcer dyspepsia
Acute hepatitis

WORKUP

Section 5 of 11  

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Lab Studies

• CBC count results are normal in uncomplicated biliary colic; an abnormality suggests complicated biliary disease such as cholecystitis.
• Aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, bilirubin, and amylase assay results are normal in uncomplicated biliary colic; an abnormality suggests a complication such as cholecystitis, cholangitis, or pancreatitis.
• If clinical suspicion warrants more extensive investigation into alternate diagnoses, consider creatine kinase and cardiac enzymes evaluation or other investigations accordingly. Minor increases in alkaline phosphatase accompanied by rises in bilirubin may be seen with choledocholithiasis. Increases in AST and ALT accompanied by right upper quadrant pain often herald the development of cholangitis.

Imaging Studies

• Abdominal ultrasound (US) is the diagnostic method of choice to confirm gallstones. US is sensitive (95%), and its specificity is guided by pretest probability.
• • The picture of a classic history for biliary colic and gallstones within the gallbladder with some wall edema increases specificity. An atypical history with a single large stone makes this specificity lower, with overall estimates of specificity approximately 60%.
  • The test is safe and relatively inexpensive. Negative US findings exclude biliary colic in most instances. Visualizing cystic duct obstruction, the most common cause of biliary colic, is uncommon. Biliary tract dilation also is not observed often.
• Oral cholecystography (55-85%), although at times sensitive (ie, when the gall bladder is able to be filled with contrast, sensitivity is 90%) for the evaluation of gallstones, has been replaced by US.
• • It may have advantages over US for assessing cystic duct patency and gall bladder function, but this indication is infrequent and is reserved for those with symptomatic gallstones who are elderly and not operative candidates.
  • Dissolution therapy may be contemplated, but rarely is it indicated.
• Hepatobiliary (hepatoiminodiacetic acid) scintography may have a role in evaluating acute cholecystitis. It has a role when classic symptoms of biliary colic occur and imaging studies fail to demonstrate stones (see Media file 2).
• • Generally, either cholecystokinin (CCK) or morphine is added to improve the sensitivity of the test, although much controversy surrounds the sensitivity and specificity of the addition of morphine to the procedure.
  • Ejection fractions of less than 50% have been found with those more likely to respond to cholecystectomy; however, some authorities suggest values of less than 35%. Lower ejection fractions provide increased specificity at the expense of sensitivity.
  • In the context of typical symptoms of biliary colic and an ejection fraction of 20%, these authors usually would recommend cholecystectomy.
• ERCP has a role in patients with persisting symptoms consistent with biliary colic that have failed to resolve with cholecystectomy. The aim is to primarily exclude choledocholithiasis.
• • When used with biliary manometry, ERCP is useful for predicting which patients are more likely to respond to sphincterotomy, in particular those classified as type II SOD.
  • ERCP has a therapeutic role in type I and type II SOD. It is the means by which a sphincterotomy may be performed to treat this condition.
  • Some authors use this procedure to aspirate bile, looking for crystals. Using the results of this procedure for predicting those who will respond to cholecystectomy has not been validated at this point.
• Abdominal x-ray has a very low sensitivity and specificity in the diagnosis of biliary colic. The role is to exclude other pathology (eg, bowel obstruction, perforation).
• Magnetic resonance cholangiopancreatography has the same role as ERCP in biliary disease. It offers no advantage over US but may have a role when one is looking for a retained common duct stone.
• • Patients who have had gallstones removed at ERCP (ie, those who have had a sphincterotomy), who have negative findings for cholelithiasis on US, and who are candidates for surgery should be offered cholecystectomy.
  • High-risk candidates referred for elective cholecystectomy should be considered on a case-by-case basis.
  • Patients with cholelithiasis and choledocholithiasis who are operative candidates should be offered laparoscopic cholecystectomy and CBD exploration, acknowledging a 5% chance of conversion to an open procedure.

Procedures

• Surgery is recommended for symptomatic gallstone disease, and all symptomatic individuals should be considered for laparoscopic cholecystectomy when appropriate.
• Patients at higher-than-normal operative risk must be considered individually. Cost and risk-benefit analysis does not support prophylactic cholecystectomy in asymptomatic individuals; however, it does support surgical intervention in symptomatic individuals. This is discussed in Cholelithiasis.

Histologic Findings

Cholecystectomy specimens often show changes consistent with chronic cholecystitis (see Cholecystitis). Gallstones are found in most surgical specimens.

TREATMENT

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Medical Care

Supportive measures are indicated for patients with uncomplicated biliary colic, with symptoms usually resolving within 2-3 hours. Continuous or recurrent symptoms despite analgesia likely herald a complication of gallstone disease, most commonly acute cholecystitis.

• Pain
• • Most authors favor narcotic analgesics over other agents for the immediate relief of pain. Meperidine (pethidine) at 1-1.5 mg/kg intramuscular injection (not to exceed 100 mg) every 3 hours is preferred. In view of the theoretical association with increased biliary motility and spasm, morphine generally is avoided.
  • Several controlled trials of diclofenac, tenoxicam, and ketorolac seem to have demonstrated therapeutic benefits in both pain relief and decreased likelihood of progression to acute cholecystitis. An increase in adverse effects in patients who are dehydrated or elderly should be considered. In the setting of nausea and vomiting, a parenteral route is favored.
  • Antispasmodics (eg, papaverine, atropine) and nitrates have a very limited, if any, role in the treatment of biliary colic.
• Nausea: Use metoclopramide or prochlorperazine intravenously.

Surgical Care

No acute surgical intervention is warranted because uncomplicated biliary colic resolves with conservative treatment.

• Several studies have reviewed the treatment of symptoms believed to be related to gallstones.
• • Patients who undergo elective cholecystectomy for biliary colic have shorter lengths of stay in the hospital and less complicated operative courses than those presenting with complications of gallstone disease. Relief of symptoms occurs in approximately 85% of individuals. The procedures performed were, on the average, shorter and with shorter periods of convalescence. Many authors favor elective surgery for patients with biliary colic.
  • Patients with atypical (ie, nonpain) symptoms show inconsistent relief of these symptoms (eg, fatty food intolerance, flatulent dyspepsia). Laparoscopic therapy is favored.
  • In patients with symptoms of biliary colic without gallstones, the treatment options become more difficult. A combination of a positive biliary scintography with CCK (an ejection fraction <50%) and classic symptoms appears to respond the best to cholecystectomy. In general, patients with symptoms typical of biliary colic, with normal US findings, positive scintography findings, and no evidence of acid-peptic disease, have the greatest benefit from laparoscopic cholecystectomy. Patients with symptoms that persist after cholecystectomy warrant evaluation in specialized facilities that focus on biliary motility disorders.
  • Nonsurgical treatment is selected for high-risk surgical candidates.

Consultations

Early surgical consultation is appropriate if symptoms do not resolve in the expected time frame. Persistent symptoms suggest the possibility of acute cholecystitis. In those in whom a diagnosis is established and symptoms resolve, elective consultation is appropriate.

Diet

During the acute attack, patients typically are anorectic. After resolution of the attack, some authors favor avoidance of high-fat meals. Controlled data are lacking to support this approach, and a liberal healthy diet is not unreasonable. A diet to prepare an individual for surgery is advised (eg, weight reduction in patients who are obese).

Activity

Bed rest usually is recommended until the pain resolves; patients may resume full activity thereafter.

MEDICATION

Section 7 of 11  

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NSAIDs and/or opiate agonists are used to provide pain relief. Nausea is treated with antiemetics and intravenous fluids for consequent dehydration.

Drug Category: Analgesic agents

Pain control is essential to quality patient care. NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. They are used for mild to moderate pain. Their mechanism of action is unknown, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist (eg, inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, various cell membrane functions). Opioid analgesics act at the CNS mu receptors. They are inexpensive and have proven effective.

Drug Name	Hydromorphone (Dilaudid)
Description	Potent semisynthetic opiate agonist similar in structure to morphine. Approximately 7- to 8-times as potent as morphine on mg-to-mg basis, with shorter or similar duration of action (ie, 4-5 h).
Adult Dose	1-2 mg IV/IM/SC q4h; adjust dose according to pain scale assessment
Pediatric Dose	Not established; problem rare <20 y
Contraindications	Documented hypersensitivity; do not use for obstetrical analgesia, increased intracranial pressure, or respiratory depression; ulcerative colitis; Crohn disease; relative contraindications include abdominal cramping and distention
Interactions	Additive sedation and respiratory depression with other drugs causing CNS depression; drugs inducing CYP450 metabolism (eg, rifampin, phenytoin, carbamazepine) may decrease hydromorphone effect
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Pregnancy category D with prolonged use or high doses at term; caution in patients with head injuries, may increase respiratory depression and CSF pressure; caution postoperatively and in patients with history of pulmonary disease (suppresses cough reflex); caution in patients with impaired hepatic function (decrease dose), hypothyroidism, Crohn disease, ulcerative colitis, Addison disease, or prostatic hypertrophy

Drug Name	Ibuprofen (Motrin, Advil, Ibuprin)
Description	Indicated for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult Dose	Mild to moderate pain: 400 mg PO q4-6h prn; not to exceed 3.2 g/d; IM dosing for those with concurrent nausea
Pediatric Dose	Not established; problem rare <20 y
Contraindications	Documented hypersensitivity; active peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Interactions	Coadministration with aspirin increases risk of serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase methotrexate toxicity; phenytoin levels may increase when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in patients with coagulation abnormalities or during anticoagulant therapy

Drug Name	Ketorolac (Toradol)
Description	Inhibits prostaglandin synthesis by decreasing activity of cyclooxygenase, which results in decreased formation of prostaglandin precursors.
Adult Dose	30-60 mg IM initially, followed by 15-30 mg q6h; alternatively 15-30 mg IV initially, followed by 15-30 mg IV prn; not to exceed 120 mg/d (60 mg/d in renal failure, >65 y, or <50 kg); not to exceed 5 d of treatment
Pediatric Dose	Not established; problem rare <20 y
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; do not administer into CNS
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Category D in third trimester of pregnancy; may cause acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; leukopenia (rare) usually returns to normal during ongoing therapy; discontinue therapy if persistent leukopenia, granulocytopenia, or thrombocytopenia occur; decrease dose in renal failure, >65 y, or <50 kg

Drug Category: Antiemetic agents

The CNS vomiting center (VC) may be stimulated directly by GI irritation. Increased activity of central neurotransmitters, dopamine in the chemoreceptor trigger zone, or acetylcholine in the VC appears to be a major mediator for inducing vomiting. Antidopaminergic agents (eg, metoclopramide, phenothiazines) are effective for nausea due to GI irritation.

Drug Name	Prochlorperazine (Compazine)
Description	May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system.
Adult Dose	5-10 mg PO/IM tid/qid; not to exceed 40 mg/d; alternatively, 2.5-10 mg IV q3-4h prn; not to exceed 10 mg/dose or 40 mg/d 25 mg PR bid
Pediatric Dose	Not established; problem rare <20 y
Contraindications	Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe hypotension; children <2 years or <9 kg; severe liver or cardiac disease
Interactions	Coadministration with other CNS depressants or anticonvulsants may cause additive effects
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Drug-induced Parkinson syndrome or pseudoparkinsonism occurs frequently, akathisia is most common extrapyramidal reaction in elderly persons; tardive dyskinesia may occur, especially in elderly persons (up to 40%); extrapyramidal effects most pronounced in children <5 y or elderly persons; lowers seizure threshold, caution in patients with history of seizures; caution in patients with prostatic hypertrophy, peptic ulcer, dehydration, or history of neuroleptic malignant syndrome

Drug Name	Ondansetron (Zofran)
Description	5-HT-3 receptor antagonist used when other classes fail or are contraindicated.
Adult Dose	4 mg IV q6h prn; 8 mg PO tid prn
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Although potential exists for cytochrome P-450 inducers (eg, barbiturates, rifampin, carbamazepine, phenytoin) to change half-life and clearance, dosage adjustment usually not required
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in impaired liver function; medication administered for prevention of nausea and vomiting, not for rescue of nausea and vomiting

FOLLOW-UP

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Further Inpatient Care

• In the setting of continued pain for longer than 6 hours or signs of clinical deterioration, surgical assessment should be undertaken.

Further Outpatient Care

• Patients with biliary colic should be referred for elective cholecystectomy, particularly if symptoms are recurrent.
• • Even high-risk surgical candidates should be considered for laparoscopic cholecystectomy. Good results can be achieved in these patients, and data appear to support this over ERCP. Patients who have had an ERCP remain at risk for biliary complications of gallstone disease. Good data now support laparoscopic cholecystectomy with laparoscopic CBD exploration when undertaken by experienced people rather than ERCP prior to cholecystectomy.
  • In the rare instance in which a patient has had CBD clearance with ERCP and has no residual stones on imaging, these authors favor cholecystectomy. No randomized data are available to support this; however, "once a stone former, always a stone former … until cholecystectomy."

In/Out Patient Meds

• No medications should be required after the attack has resolved, and prophylactic medications or prescriptions for outpatient analgesia have no role in this condition.

Deterrence/Prevention

• Cholecystectomy generally cures the pain of biliary colic and is the treatment of choice for this condition. Avoidance of fatty meals does not reduce symptoms of biliary colic, nor does it result in less frequent attacks.

Complications

• Biliary colic lasting longer than 6 hours, fever, and right upper quadrant tenderness may indicate acute cholecystitis; the addition of jaundice to the above symptoms and signs implies cholangitis.
• After the initial presentation, 30% of patients have no further attacks and the approximate frequency of recurrent symptoms after an initial attack is 30% in the 2 years following. Serious complications following an initial attack of biliary colic are uncommon, with a frequency of approximately 1% per year. One study favors routine cholecystectomy for those with symptoms consistent with biliary colic. This is based on reduced overall cost, decreased number of hospitalizations, reduced emergency department visits, and, importantly, diminished likelihood of conversion from a laparoscopic to open procedure and the complications from this surgery.

Prognosis

• Recurrent biliary colic occurs in 50-75% of patients after the initial episode. Most patients who develop complications such as cholecystitis experience biliary colic prior to the complications. A recent cost analysis appears to support referral of those with symptoms of biliary colic for cholecystectomy. Of greatest importance is the fact that biliary colic is the most sensitive and specific symptom of symptomatic cholelithiasis, and one should be aware that other symptoms (eg, bloating) have low specificity for symptomatic gallstone disease.
• Cholecystectomy cures symptoms of biliary colic in approximately 80-85% of patients with gallstones on ultrasound findings. Nonpain symptoms related to cholelithiasis are relieved inconsistently (approximately 40%) by cholecystectomy.
• Postcholecystectomy syndrome encompasses an array of clinical symptoms that persist following cholecystectomy. They may be of biliary or nonbiliary origin. More often, these are symptoms such as bloating, excessive flatulence, and fatty-food intolerance. In any event, if the primary indications for cholecystectomy are these atypical symptoms, it is imperative that during informed consent a patient is made aware that these are not improved consistently following cholecystectomy. Every good operation has its indications and limitations. To discuss and document these for every individual patient is important.
• • Disorders that warrant exclusion, in the event that pain persists following cholecystectomy, include those of both biliary and nonbiliary origins. Retained stones in the CBD (ie, choledocholithiasis) should have been excluded with an operative cholangiogram, and this is a good place to start with the workup of persisting symptoms. Clinical data that would support choledocholithiasis include any feature of cholangitis, clinical stigmata of obstruction, and laboratory tests (ie, increased bilirubin or liver enzymes following attacks).
  • Nonbiliary causes include gastrointestinal disorders (eg, reflux esophagitis, peptic ulcer disease), nongastrointestinal disorders (eg, atypical angina), and, importantly, functional disorders such as irritable bowel syndrome (IBS). Another word of caution is that 2 common conditions may coexist (ie, gallstones and IBS). To reiterate, a careful history is the cornerstone of establishing a provisional diagnosis of biliary colic in an individual (commonly a middle-aged female) who may present with IBS and gallstones on US findings.
• The difficult patient is one from whom data on the most appropriate therapy is not available. This is the high-risk surgical patient with biliary colic. A good study that endeavors to address this is that by Targarona et al, which favors laparoscopic cholecystectomy over ERCP with sphincterotomy for choledocholithiasis (Targarona, 1996). In 1998, Carr-Locke's group (Davidson, 1998) showed that, even with sphincterotomy, the risk of recurrent biliary tract–related symptoms or complications was significant (approximately 20%). A good review article relating to the new challenges in biliary tract disease is that by Stiegmann (Stiegmann, 1998).

Patient Education

• Information relating to the options available in the treatment of biliary colic should be provided.
• Advise patients that, over the next 2 years, they have a 50% chance of a repeat attack of biliary colic and that they also have a chance that subsequent attacks may be associated with complications such as cholangitis; however, this is uncommon.
• The limitations of surgery probably should be outlined; in particular, recurrent pain consistent with biliary colic may occur in 10-20% of people after surgery and that nonpain symptoms are relieved inconsistently.
• For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Center and Cholesterol Center. Also, see eMedicine's patient education articles Gallstones and Abdominal Pain in Adults.

MISCELLANEOUS

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Medical/Legal Pitfalls

• Care should be taken to establish the correct diagnosis. Do not advise that because gallstones are present on imaging studies and the patient has pain, cholecystectomy will cure the problem.
• Postcholecystectomy syndrome was discussed earlier (see Prognosis), and patients must be made aware that the procedure of cholecystectomy works well for classic biliary colic symptoms; however, pain may recur after the procedure. Recurrence of classic symptoms following cholecystectomy may signify choledocholithiasis. The persistence of atypical symptoms often signifies that the diagnosis was incorrect. The operation is not a cure-all, and some individuals develop new symptoms following the procedure. Providing realistic expectations and clear communication both before and after the procedure are key to avoiding potential litigation.

Special Concerns

• People with cirrhosis and pregnant individuals with biliary colic should be considered on a case-by-case basis. Most would suggest that those with an initial attack of uncomplicated biliary colic should be observed.
• • In patients with symptomatic gallstone disease and Child-Turcotte-Pugh class A/B cirrhosis, elective laparoscopic cholecystectomy can be performed safely, and some authors believe that this procedure should be considered for individuals with symptomatic gallstone disease to prevent biliary tract complications.
  • Symptomatic gallstone disease in pregnancy can be treated safely with laparoscopic cholecystectomy in the second trimester and should primarily target those with severe symptoms. However, biliary colic is uncommon during pregnancy.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Mechanism of biliary colic.
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Media file 2:  Potential sites of gallbladder stones.
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Media file 3:  Gallbladder stones.
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Media file 4:  Choledocholithiasis.
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Media file 5:  HIDA (or gallbladder) scan.
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Media file 6:  HIDA (or gallbladder) scan.
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Media file 7:  HIDA (or gallbladder) scan.
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Media type:  Image

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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Article Last Updated: Mar 30, 2006