Biliary Colic

Question 1

What is biliary colic?

Answer 1

Biliary colic refers to sudden onset of epigastric or right upper quadrant pain caused by a transient blockage within the biliary tree. Biliary colic is typically caused by the gallbladder contracting and forcing a gallstone or sludge against the gallbladder outlet or cystic duct opening. Biliary colic is described as an intense, dull discomfort, typically constant in nature in the right upper quadrant, epigastrium, or substernal area with possible radiation to the back or right shoulder blade. Pain from biliary colic is often associated with fatty food intake, nausea, and vomiting.

Question 2

Is biliary colic a diagnosis of inclusion or exclusion?

Answer 2

Biliary colic is a diagnosis of exclusion, meaning it is considered after ruling out more severe, can’t-miss diagnoses.

Question 3

What are the complications associated with gallstones?

Answer 3

• Cholecystitis, which is assocated with gallbladder inflammation secondary to gallstones that results in right upper quadrant pain, fever, and leukocytosis.
• Choledocholithiasis, which is the presence of a gallstone in the common bile duct and can be further complicated by acute cholangitis which presents with fever, abdominal pain, and jaundice caused by infection from biliary obstruction.
• Acute cholangitis, which is associated with right upper quadrant pain, jaundice, fever, leukocytosis, and hyperbilirubinemia. The combination of fever, abdominal pain, and jaundice is known as Charcot’s triad, which is highly suggestive of this condition.

Question 4

What is the first step in assessing a patient with suspected biliary colic?

Answer 4

Perform an ABCDE assessment to determine if the patient is stable or unstable. If unstable, consider cholangitis or another critical diagnosis and begin acute stabilization.

Question 5

What are the key stabilization steps for an unstable patient with biliary colic, but there’s a high degree of a more severe condition?

Answer 5

Intubation if necessary, IV access, fluid resuscitation, and looking for signs of sepsis or other causes of instability.

Question 6

What is the first step for a stable patient with suspected biliary colic?

Answer 6

Start supportive care, including IV fluids, bowel rest, pain management, antispasmodics, and antiemetics as needed.

Question 7

What are the characteristic symptoms of biliary colic?

Answer 7

Colicky right upper quadrant pain, often described as cramping or sharp pain that starts and ends suddenly in spasms. It can radiate to the shoulder or scapula and may be associated with fatty food intake, nausea, and vomiting.

Question 8

What is Boa’s sign in biliary disease?

Answer 8

Boa’s sign refers to hyperesthesia in the right scapular region, which can be associated with gallbladder disease.

Question 9

A positive Murphy sign on physical exam is highly suggestive of

Answer 9

acute cholecystitis.

Question 10

What is Murphy’s sign, and what does it indicate?

Answer 10

Murphy’s sign is pain on palpation of the right upper quadrant while the patient takes a deep breath, leading to an abrupt cessation of inspiration. A positive Murphy’s sign suggests gallbladder inflammation, such as acute cholecystitis. Patients with a prior history of biliary colic from gallstones who present with fever, right upper quadrant abdominal pain, and leukocytosis should be evaluated for acute cholecystitis.

Question 11

What are the major risk factors for gallbladder and biliary disease?

Answer 11

Female sex, obesity, rapid weight loss, history of gallstones, and age over 40.

Question 12

What lab tests should be ordered in suspected biliary colic?

Answer 12

Complete blood count (CBC), Complete metabolic panel (CMP) that inludes an alkaline phosphatase (ALP) and other liver function tests (LFTs) including fractionated bilirubin (direct and indirect), amylase, and lipase.

Question 13

What imaging study is the first-line diagnostic tool for biliary colic?

Answer 13

Ultrasound is the first-line imaging study to assess for gallstones, gallbladder inflammation, or common bile duct dilation.

Question 14

What lab and imaging findings suggest gallbladder inflammation (cholecystitis)?

Answer 14

Leukocytosis and elevated ALP. Ultrasound may show gallstones, gallbladder wall thickening >3 mm, pericholecystic fluid, and a positive sonographic Murphy’s sign. Findings are centered around the gallbladder itself.

Question 15

What findings suggest acute cholangitis?

Answer 15

Jaundice, fever, sepsis signs, leukocytosis, elevated ALP, direct bilirubin. Ultrasound may show common bile duct stones, biliary dilation, thickened bile duct walls, and possibly debris within the gallbladder (biliary sludge).

Question 16

What condition requires urgent intervention if found on assessment of biliary colic?

Answer 16

Acute cholangitis, also known as ascending cholangitis, which requires urgent antibiotics and potential biliary decompression (ERCP).

Question 17

What distinguishes biliary colic from cholecystitis and cholangitis?

Answer 17

Biliary colic does not have inflammation or infection. Labs are typically normal or show mild ALP elevation, and ultrasound may show gallstones but no gallbladder inflammation.

Question 18

What are some differential diagnoses outside of biliary colic other than biliary condtions?

Answer 18

Pancreatitis, pancreatic pseudocyst, hepatitis or liver failure, peptic ulcer disease, bowel obstruction, and vascular causes like mesenteric ischemia.

Question 19

What are the major ultrasound findings in biliary colic?

Answer 19

Presence of gallstones in the gallbladder or common bile duct without signs of gallbladder wall thickening, pericholecystic fluid, or biliary dilation.

Question 20

What is a critical pertinent negative for acute cholecystitis?

Answer 20

Patients do not normally have hyperbilirubinemia or jaundice in cholecystitis because the obstruction in cholecystitis is at the cystic duct, leading to gallbladder inflammation, not obstruction at the common bile duct or upstream at the hepatic ducts.

Question 21

What is the next step if ultrasound findings are inconclusive but suspicion for biliary disease remains high?

Answer 21

Consider magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) for further evaluation of biliary obstruction.

Question 22

In what instance is elevated direct bilirubin assoicated with cholecystitis and what is this sign?

Answer 22

Mirizzi syndrome (compression of the common bile duct by a gallstone in the cystic duct or Hartmann’s pouch) can obstruct bile flow and elevate conjugated bilirubin. Mirizzi syndrome presents with right upper quadrant pain, jaundice, and fever as well. Additionally, compression of the hepatic ducts can also occur. CT would need to be used in order to demonstrate dilatation of the biliary system above the neck of the gallbladder or a stone.

Question 23

How is biliary colic managed after ruling out severe conditions?

Answer 23

Supportive care with pain management, bowel rest, IV fluids, and potential elective cholecystectomy for recurrent symptoms.

Question 24

What is the goal of management for patients with cholecystitis?

Answer 24

The Patients who present with a combination of right upper quadrant pain, fever, and leukocytosis, with ultrasound findings such as pericholecystic fluid and inflammation of the gallbladder wall, should be effectively diagnosed with acute cholecystitis and should be evaluated to determine surgical candidacy based on risk stratification. While this is ongoing, the most immdiate step is to provide empiric intravenous antibiotics, supportive care, and surgical consultation for a non-emergent cholecystectomy.

Question 25

Patients with suspected acute cholangitis because of the findings of right upper quadrant abdominal pain, fever, and jaundice (Charcot Triad), will reqiure an emergent … ?

Answer 25

Patients with suspected acute cholangitis should undergo endoscopic retrograde cholangiopancreatography (ERCP) for both diagnosis and treatment with biliary drainage. ERCP with or without an initial ultrasound, should be performed in patients with suspected acute cholangitis since it can be used to both diagnose and treat the underlying obstruction via biliary duct decompression and removal of stones. In addition, patients with acute cholangitis should be admitted to the hospital and administered IV hydration, antiemetics, analgesia, and empiric antibiotics.

Question 26

The preferred intravenous (IV) antibiotic regimen for acute cholangitis is …?

Answer 26

broad-spectrum antibiotic that covers gram-negative bacilli (e.g., Escherichia coli, Klebsiella spp.), enteric streptocci, coliforms, and anaerobes (e.g., Bacteroides spp.). This is typically a combination of Metronidazole (Flagyl) and Ceftriaxone or Cefepime.

Question 27

A palpable gallbladder in the presence of jaundice is a positive ________ sign.

Answer 27

Positive Courvoisier sign. This is where the patient is jaundiced and touching the gallbladder does not ellicit a pain response (non-tender) even while the gallbladder is enlarged. Some patients may even be depressed or have altered mentation. A positive Courvoisier sign must never be missed as it is most suggestive of pancreatic or gallbladder malignancy.