Biliary colic

Biliary colic is the clinical manifestation of uncomplicated gallstone disease. It refers to recurrent attacks of severe pain of typical character caused by gallstones. It is not dangerous, but it is bothersome. Treatment involves avoidance of fatty foods and analgesics during attacks. The only definitive treatment is cholecystectomy.

Pathology

Biliary pain occurs because the gallbladder tries to contract to push out a gallstone which is impacted in the gall bladder neck, which increases the pressure in the gallbladder, or because the stones irritate the gall bladder wall during contraction.

Clinical features

Uncomplicated gallstone disease presents with attacks of biliary colic. This pain is intense, dull, constant, and is usually located in the right upper quadrant or epigastrium. The pain may radiate to the back or shoulder. The patient usually feels a strong urge to keep moving, rather than lying still. Worsening after food intake is typical but not always present. Sweating and nausea/vomiting is usually also present. Despite the name, the pain is usually constant rather than colicky. The attack usually lasts a few hours and rarely less than 30 minutes. These attacks often recur.

Diagnosis and evaluation

In uncomplicated gallstone disease, there are no elevated inflammatory parametres or signs of cholestasis (elevated ALP/GGT or bilirubin), and no fever. Ultrasound can show the presence of cholelithiasis, but imaging is not necessary for the diagnosis if the clinical features are typical and complicated gallstone is ruled out.

Treatment

Biliary colic itself is not an indication for surgery, unless the patient has many episodes of them. In many cases, patients can live with these attacks if they're rare enough and not that severe (or painkillers have sufficient efficacy).The only definitive way to prevent episodes is cholecystectomy.

Reducing fatty foods in the diet reduces the risk for attacks.

Analgesia during the attacks is important. The first choice is NSAIDs like ketorolac, diclofenac, or ibuprofen, and the second choice is opioids like morphine. Many are reluctant to use morphine as it theoretically contricts the sphincter of Oddi, and alternative opioids which cause less constriction (like buprenorphine or meperidine) are often used instead. However, systematic reviews have found that all opioids cause sphincter constriction, and there is no evidence that morphine is worse than other opioids in this regard.

Peripheral anticholinergics like butylscopolamine/hyoscine (Buscopan®) can reduce the biliary spasm and improve the pain when combined with NSAIDs, but they've not shown to be better than NSAIDs alone.