Biliary Colic

Question 1

… … refers to a pain in the RUQ/epigastrium caused by gallstones.

Answer 1

Biliary colic refers to a pain in the RUQ/epigastrium caused by gallstones.

Question 2

… (gallstones) refers to the development of a solid deposit or ‘stone’ within the gallbladder.

Answer 2

Cholelithiasis (gallstones) refers to the development of a solid deposit or ‘stone’ within the gallbladder.

Question 3

Cholelithiasis (gallstones) refers to the development of a solid deposit or ‘stone’ within the gallbladder.

Answer 3

Though largely asymptomatic in a significant proportion of patients they become problematic. In the UK around 60,000 cholecystectomies are performed each year.

Question 4

Gallstones affect up to …% of the population. The prevalence of gallstones increase with advancing age before levelling off in the sixth - seventh decade of life. They are more common in women and tend to affect those of caucasian, Native American and hispanic backgrounds more.

Answer 4

Gallstones affect up to 20% of the population. The prevalence of gallstones increase with advancing age before levelling off in the sixth - seventh decade of life. They are more common in women and tend to affect those of caucasian, Native American and hispanic backgrounds more.

Question 5

There are a number of risk factors are associated with the development of cholelithiasis: (9)

Answer 5

Age
Female sex
Genetic predisposition
Obesity
Rapid weight loss / prolonged fasting
Diabetes
Medications (e.g. oestrogen replacement therapy, ceftriaxone, octreotide)
Crohn's disease
Diet (high in triglycerides, refined carbohydrates)

Question 6

Biliary colic is a self-limiting pain in the …

Answer 6

Biliary colic is a self-limiting pain in the epigastrium/RUQ.

Question 7

Biliary colic is a self-limiting pain in the epigastrium/RUQ.
Though termed ‘colic’ the pain is normally constant with episodes typically lasting ..-… It is frequently associated with nausea and may precipitate vomiting.

Answer 7

Though termed ‘colic’ the pain is normally constant with episodes typically lasting 30 minutes - 6 hours. It is frequently associated with nausea and may precipitate vomiting.

Question 8

Clinical features of biliary colic

Answer 8

Intermittent RUQ/epigastric pain

Nausea / vomiting

Question 9

Clinical features of…

Answer 9

Biliary colic

Question 10

An …. is highly sensitive for the diagnosis of gallstones.

Answer 10

An USS abdomen is highly sensitive for the diagnosis of gallstones.

Question 11

Patients with suspected gallstones should have an abdominal USS and LFTs arranged:

Why?

Answer 11

USS: An abdominal USS is an excellent non-invasive, radiation free investigation for gallstones. Of note, though an USS may identify gallstones - it cannot guarantee the pain experienced by the patient has been caused by the stones. It can also assess the CBD for dilation and sometimes identify stones in the CBD.
LFTs: Liver function tests represent an essential component of the work-up. Derangement may be indicative of stones within the biliary system (which can be asymptomatic). It is essential to identify patients with CBD stones prior to any cholecystectomy. See the management section for more details.

Question 12

Biliary colic is managed with symptomatic relief and …

Answer 12

Biliary colic is managed with symptomatic relief and elective cholecystectomy.

Question 13

Symptomatic management and prevention

Conservative measures may be used to treat acute symptoms and reduce episodes of colic:

Answer 13

Analgesia: Simple pain relief with paracetamol and NSAIDs (in the absence of contra-indications). Occasionally opioid analgesia may be required.
Diet: A low-fat diet may be trialled with some patients experiencing a significant reduction in the number and severity of episodes.

Question 14

Surgical management of biliary colic

Answer 14

Typically once gallstones have become symptomatic, they are likely to be troublesome in the future. For most patients an elective cholecystectomy is indicated.

A routine general surgery review with a view to considering operative management should be arranged. In patients with significant co-morbidities, a cholecystectomy may represent unacceptable risk and as such conservative measures trialled.

Prior to cholecystectomy it is key that CBD stones are excluded. All patients will have had an USS and set of LFTs as a minimum. If there is suspicion of CBD stones (e.g. dilated CBD or CBD stone on USS, raised bilirubin on LFTs) then there are two main options:

Question 15

Prior to cholecystectomy it is key that what is excluded?

Answer 15

Prior to cholecystectomy it is key that CBD stones are excluded. All patients will have had an USS and set of LFTs as a minimum. If there is suspicion of CBD stones (e.g. dilated CBD or CBD stone on USS, raised bilirubin on LFTs) then there are two main options:

MRCP +/- ERCP: MRCP allows for confirmation of stones in the biliary tree. If present ERCP allows for therapeutic intervention with stone retrieval, sphincterotomy and stent placement prior to cholecystectomy.
On-table cholangiogram: Less commonly available and technically challenging. During the laparoscopic cholecystectomy the bile duct is intubated to allow the injection of dye with fluoroscopy in-theatre to diagnose stones in the biliary tree. Various techniques may then be used to retrieve/expel stones.

Question 16

If there is suspicion of CBD stones (e.g. dilated CBD or CBD stone on USS, raised bilirubin on LFTs) then there are two main options:

Answer 16

MRCP +/- ERCP: MRCP allows for confirmation of stones in the biliary tree. If present ERCP allows for therapeutic intervention with stone retrieval, sphincterotomy and stent placement prior to cholecystectomy.
On-table cholangiogram: Less commonly available and technically challenging. During the laparoscopic cholecystectomy the bile duct is intubated to allow the injection of dye with fluoroscopy in-theatre to diagnose stones in the biliary tree. Various techniques may then be used to retrieve/expel stones.

Question 17

… allows for confirmation of stones in the biliary tree. If present … allows for therapeutic intervention with stone retrieval, sphincterotomy and stent placement prior to cholecystectomy.

Answer 17

MRCP allows for confirmation of stones in the biliary tree. If present ERCP allows for therapeutic intervention with stone retrieval, sphincterotomy and stent placement prior to cholecystectomy.

Question 18

On-table …: Less commonly available and technically challenging. During the laparoscopic cholecystectomy the bile duct is intubated to allow the injection of dye with fluoroscopy in-theatre to diagnose stones in the biliary tree. Various techniques may then be used to retrieve/expel stones.

Answer 18

On-table cholangiogram: Less commonly available and technically challenging. During the laparoscopic cholecystectomy the bile duct is intubated to allow the injection of dye with fluoroscopy in-theatre to diagnose stones in the biliary tree. Various techniques may then be used to retrieve/expel stones.