Biliary Colic – Causes, Symptoms, Diagnosis, Treatment

Biliary Colic is a common presentation of a stone in the cystic duct or common bile duct of the biliary tree. Colic refers to the type of pain that “comes and goes,” typically after eating a large, fatty meal which causes contraction of the gallbladder. However, the pain is usually constant and not colicky. Treatment of this disease is primarily surgical, involving removal of the gallbladder, typically using a laparoscopic technique. This medical condition does not typically require hospital admission.[rx][rx] Biliary colic generally refers to the pain that occurs from a temporary obstruction of the biliary tree which resolves on its own. Prolonged obstruction of the biliary tree or complete impaction of a stone within the biliary tree will eventually lead to cholecystitis or cholangitis, at which pain the pain will constant and increasing.

Causes Of Biliary Colic

Biliary pain is most frequently caused by obstruction of the common bile duct or the cystic duct by a gallstone. 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.^[rx]

There are three main pathways in the formation of gallstones

• Cholesterol supersaturation – Normally, bile can dissolve the amount of cholesterol excreted by the liver. But if the liver produces more cholesterol than bile can dissolve, the excess cholesterol may precipitate as crystals. Crystals are trapped in gallbladder mucus, producing gallbladder sludge. With time, the crystals may grow to form stones and occlude the ducts which ultimately produce the gallstone disease.
• Excess bilirubin – Bilirubin, a yellow pigment derived from the breakdown of red blood cells, is secreted into bile by liver cells. Certain hematologic conditions cause the liver to make too much bilirubin through the processing of breakdown of hemoglobin. This excess bilirubin may also cause gallstone formation.
• Gallbladder hypomotility or impaired contractility – If the gallbladder does not empty effectively, bile may become concentrated and form gallstones.
• There’s too much bilirubin in your bile – Conditions like cirrhosis, infections, and blood disorders can cause your liver to make too much bilirubin.
• Your gallbladder doesn’t empty all the way – This can make your bile very concentrated.
• There’s too much cholesterol in your bile – Your body needs bile for digestion. It usually dissolves cholesterol. But when it can’t do that, the extra cholesterol might form stones.
• Your gallbladder doesn’t empty correctly – If your gallbladder doesn’t empty completely or often enough, bile may become very concentrated, contributing to the formation of gallstones.
• Being female
• Obesity
• Increasing age
• Losing or gaining weight quickly
• High-calorie diet
• Pregnancy
• Hormone therapy
• Diabetes

https://www.youtube.com/watch?v=gbcOzfkbDkc

The Following Factors Are Known To Increase The Risk Of Gallstones

• Age – The risk of developing gallstones increases with age, especially after you reach the age of 40.
• Genes – If someone in your family has had gallstones.
• Sex – Women are more likely to get gallstones than men. The female sex hormone estrogen is believed to increase the risk of gallstones.
• Cirrhosis – A severe liver disease caused by metabolic disorders or excessive consumption of alcohol.
• Being very overweight.
• Losing a lot of weight in a short time – This happens a lot in very obese people who have surgery to make their stomach smaller.
• Functional problems of the gallbladder – The organ cannot contract (squeeze bile out) properly.
• Short bowel syndrome – A disorder that can develop after surgical removal of a large segment of the small bowel.
• Special high – calorie liquid food.
• Hemolysis – A disease that causes an increased breakdown of red blood cells.
• Pregnancy.
• Using the contraceptive pill or estrogen tablets during menopause (hormone therapy).
• Diabetes.

Symptoms Of Biliary Colic

Diagnosis Of Biliary Colic

Your doctor will do a physical exam and might order tests including

• Full blood count (FBC)
• Liver function tests (LFTs)
• Serum creatinine
• CRP
• Serum amylase
• Urine dipstick
• FBC and CRP – assess for the presence of any inflammatory response, which will be raised in cholecystitis
• LFTs – biliary colic and acute cholecystitis are likely to show a raised ALP (indicating ductal occlusion), yet ALT and bilirubin should remain within normal limits (unless a Mirizzi syndrome, discussed below)
• Amylase (or lipase) – to check for any evidence of pancreatitis
• Blood tests – These check for signs of infection or blockage and rule out other conditions.
• Ultrasound – This makes images of the inside of your body.
• Abdominal ultrasound – This test is the one most commonly used to look for signs of gallstones. Abdominal ultrasound involves moving a device (transducer) back and forth across your stomach area. The transducer sends signals to a computer, which creates images that show the structures in your abdomen.
• CT scan – Specialized X-rays let your doctor see inside your body, including your gallbladder.
• Magnetic resonance cholangiopancreatography (MRCP) – This test uses a magnetic field and pulses of radio wave energy to take pictures of the inside of your body, including your liver and gallbladder.
• Cholescintigraphy (HIDA scan) – This test can check whether your gallbladder squeezes correctly. Your doctor injects a harmless radioactive material that makes its way to the organ. A technician can then watch its movement.
• Endoscopic retrograde cholangiopancreatography (ERCP) – Your doctor runs a tube called an endoscope through your mouth down to your small intestine. They inject a dye so they can see your bile ducts on a camera in the endoscope. They can often take out any gallstones that have moved into the ducts.
• Endoscopic ultrasound (EUS) – This procedure can help identify smaller stones that may be missed on an abdominal ultrasound. During EUS your doctor passes a thin, flexible tube (endoscope) through your mouth and through your digestive tract. A small ultrasound device (transducer) in the tube produces sound waves that create a precise image of surrounding tissue.

Treatment Of Biliary Colic

Non-Pharmacological

• Supportive therapy and dietary modifications –  elective cholecystectomy only for symptomatic patients who are surgical candidates or asymptomatic patients at risk of gallbladder cancer
• Supportive therapy – Fasting or dietary modification (decreased fat intake)

Medication

• Spasmolytics – (e.g., dicyclomine)
• Analgesia – NSAIDs, opioids
• Oral ursodeoxycholic acid – has also been used to help dissolve gallstones.
• Electrolyte and Fluid imbalance – Initial management includes the relief of symptoms and correcting electrolyte and fluid imbalance that may occur with vomiting.^[rx]
• Antiemetics – such as dimenhydrinate, are used to treat nausea.^[rx] Ondansetron (Zofran), Promethazine (Phenergan)
• Antispasmodic are preferred – Scopolamine or Glycopyrrolate (Robinul)
  1. Parenteral: 0.1 to 0.2 mg IV or IM
  2. Oral: 1.0 to 2.0 mg orally bid to tid
• Pain may be treated with anti-inflammatories NSAIDs – such as ketorolac or diclofenac.^[rx]
• Opioids, such as morphine – less commonly may be used.^[rx] NSAIDs are more or less equivalent to opioids.^[rx]
• Hyoscine butylbromide – an antispasmodic, is also indicated in biliary colic.^[rx]
• Extracorporeal Shock Wave Lithotripsy (ESWL)
• Antibiotics – In biliary colic, the risk of infection is minimal and therefore antibiotics are not required. The presence of infection indicates cholecystitis.^[rx]
• Cholesterol gallstones – can sometimes be dissolved with ursodeoxycholic acid taken by mouth, but it may be necessary for the person to take this medication for years.^[rx]

Surgery

There Are Following Types of Surgical Options For Cholecystectomy

• Open cholecystectomy – is performed via an abdominal incision (laparotomy) below the lower right ribs. Recovery typically requires 3–5 days of hospitalization, with a return to normal diet a week after release and to normal activity several weeks after release.^[rx]
• Laparoscopic cholecystectomy – introduced in the 1980s, is performed via three to four small puncture holes for a camera and instruments. Post-operative care typically includes a same-day release or a one-night hospital stay, followed by a few days of home rest and pain medication.^[rx]
• Laparoscopic cholecystectomy – (removal of the gallbladder through multiple small incisions; this is less invasive and a more commonly used technique)
• Lithotripsy – (the technique that uses electric shock waves to dissolve gallstones; it is not commonly used today). Open cholecystectomy (removal of the gallbladder through a single, large incision; this is a more invasive and less commonly used technique)

References