Biliary Colic Flashcards
What is biliary colic?
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.
Is biliary colic a diagnosis of inclusion or exclusion?
Biliary colic is a diagnosis of exclusion, meaning it is considered after ruling out more severe, can’t-miss diagnoses.
What are the complications associated with gallstones?
- 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.
What is the first step in assessing a patient with suspected biliary colic?
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.
What are the key stabilization steps for an unstable patient with biliary colic, but there’s a high degree of a more severe condition?
Intubation if necessary, IV access, fluid resuscitation, and looking for signs of sepsis or other causes of instability.
What is the first step for a stable patient with suspected biliary colic?
Start supportive care, including IV fluids, bowel rest, pain management, antispasmodics, and antiemetics as needed.
What are the characteristic symptoms of biliary colic?
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.
What are the major ultrasound findings in biliary colic?
Presence of gallstones in the gallbladder or common bile duct without signs of gallbladder wall thickening, pericholecystic fluid, or biliary dilation.
What is Boa’s sign in biliary disease?
Boa’s sign refers to hyperesthesia in the right scapular region, which can be associated with gallbladder disease.
What is Murphy’s sign, and what does it indicate?
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.
A positive Murphy sign on physical exam is highly suggestive of
acute cholecystitis.
What are the major risk factors for gallbladder and biliary disease?
Female sex, obesity, rapid weight loss, history of gallstones, and age over 40.
What lab tests should be ordered in suspected biliary colic?
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.
What imaging study is the first-line diagnostic tool for biliary colic?
Ultrasound is the first-line imaging study to assess for gallstones, gallbladder inflammation, or common bile duct dilation.
A 44-year-old woman presents to the emergency department with severe right upper quadrant abdominal pain. The pain started last night after eating a cheeseburger and has not improved. The pain radiates to the right shoulder. Past medical history is significant for obesity and hypertension, for which the patient takes amlodipine. Temperature is 38.5°C (101.3 °F), pulse is 108/min, blood pressure is 136/89 mmHg, respirations are 18/min, and Sp02 is 99% on room air. Palpation of the right upper quadrant during inspiration causes significant pain and an abrupt cessation of inspiration. Serum white blood cell count is 18,000. Abdominal ultrasound shows a distended and thickened gallbladder with surrounding edema and gallstones. The common bile duct appears within normal limits. What would be the best next step in management?
This patient’s combination of right upper quadrant pain, fever, leukocytosis, and ultrasound findings confirm the diagnosis of acute cholecystitis. Patients like this one, who are diagnosed with acute cholecystitis and are good surgical candidates, should have intravenous antibiotics, supportive care, and surgical consultation for non-emergent cholecystectomy. Once acute cholecystitis is diagnosed, supportive care with empiric antibiotics should be initiated. Patients can either have early or delayed non-emergent cholecystectomy based on risk stratification. Patients who progress despite antibiotics, such as those with continuous high fevers or hemodynamic instability should have an emergent cholecystectomy. Patients with complicated acute cholecystitis should also have emergent cholecystectomy as these complications may be fatal. Complications include gallbladder gangrene/necrosis, perforation, and emphysematous cholecystitis.
What lab and imaging findings suggest gallbladder inflammation (cholecystitis)?
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.
What findings suggest acute cholangitis?
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).
A 62-year-old man is evaluated in the emergency department for severe, constant abdominal pain that started this morning and subjective fevers. The patient states that for the past few days he has experienced intense abdominal pain after meals that is associated with nausea and vomiting. Temperature is 38.5 °C (101.3 °F), pulse is 122/min, blood pressure is 100/89 mmHg, respirations are 10/min, and Sp02 is 99% on room air. On physical examination, the patient is ill-appearing and jaundiced. The right upper quadrant is tender to palpation. There is no tenderness in the epigastric region, and no rebound, rigidity, or guarding. Serum white blood cell count is elevated. Liver chemistries show elevations in AST, ALT, alkaline phosphatase, and direct bilirubin. Amylase and lipase are within normal limits. CT of the abdomen and pelvis shows a dilated common bile duct and no other abnormalities. What is the most likely diagnosis?
Acute cholangitis is a potentially life-threatening complication of gallstones. It presents with right upper quadrant abdominal pain, fever, hyperbilirubinemia, and leukocytosis. Fever, abdominal pain, and jaundice is called Charcot triad and is suggestive of acute cholangitis. Clinical history, physical examination, and blood work demonstrating a cholestatic picture can guide the workup. Other causes of right upper quadrant pain and fever that should be In the differential are acute cholecystitis, liver abscess, and gallstone pancreatitis. ERCP can definitively diagnose the condition and also treat it with biliary drainage and stone removal. Abdominal ultrasound can demonstrate a dilated common bile duct and/or common bile duct stone. It should be treated with broad-spectrum antibiotics and supportive care. Biliary drainage is required and can be performed endoscopically (ERCP), percutaneously, or with surgery in patients who have failed the other types of treatment or are not candidates for it. Elective cholecystectomy can be performed once the cholangitis is resolved.
What condition requires urgent intervention if found on assessment of biliary colic?
Acute cholangitis, also known as ascending cholangitis, which requires urgent antibiotics and potential biliary decompression (ERCP).
A 95-year-old man presents to the emergency department with abdominal pain. The patient has coronary artery disease with a drug-eluting stent placed two months ago, heart failure with EF of 10%, stage IV COPD requiring home oxygen, and severe pulmonary hypertension. Temperature is 39.6 °C (103.3 °F), pulse is 106/min, blood pressure is 78/48 mmHg, respirations are 20/min, and SpOz is 94% on 4 liters of oxygen via nasal cannula. On examination, the patient is ill-appearing. There is moderate right upper quadrant tenderness to palpation but no rebound, rigidity, or guarding. Serum white blood cell count is elevated. Abdominal ultrasound shows a common bile duct measuring 13 mm with the presence of a stone. Intravenous fluids and piperacillin-tazobactam are started. The patient undergoes endoscopic retrograde cholangiopancreatography (ERCP) but the biliary tree cannot be cannulated and the procedure is stopped. Which of the following is the most appropriate treatment for the patient?
A) Laparoscopic cholecystectomy
B) Repeat ERCP
C) Open cholecystectomy
D) Intravenous antibiotics and conservative management
E) Percutaneous biliary drain placement
Patients with acute cholangitis from choledocholithiasis need emergent ERCP, IV fluids, and IV antibiotics. If ERCP is unsuccessful or if it is contraindicated, then a biliary drain can be placed percutaneously by radiology or, less commonly, via open surgery. Patients with choledocholithiasis (stone in the common bile duct [CBD]) usually present with right upper quadrant abdominal pain, nausea, vomiting, and jaundice. These patients are at high risk for developing acute (ascending) cholangitis. Patients with cholangitis present with choledocholithiasis and signs of infection (e.g., fever, leukocytosis, bacteremia). Patients generally appear ill and have a high risk of developing septic shock. When cholangitis is suspected or confirmed patients should receive aggressive IV fluid resuscitation and IV antibiotics, and emergent ERCP should be performed.
Some patients with acute cholangitis from choledocholithiasis are unable to undergo ERCP or an ERCP has been unsuccessful. In these cases, a drain needs to be placed in the biliary duct for decompression. This can be performed via open surgery or percutaneously by a radiologist. Percutaneous drainage is considered very safe as it can be done with only local anesthetic if necessary. This patient is 95 years old, frail, and has end-stage COPD, end-stage CHF, recent percutaneous coronary intervention, and severe pulmonary hypertension. He is a high-risk patient for anesthesia and surgery, with a high likelihood of mortality. Therefore, less-invasive procedures should be considered first.
What distinguishes biliary colic from cholecystitis and cholangitis?
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.
What are some differential diagnoses outside of biliary colic other than biliary condtions?
Pancreatitis, pancreatic pseudocyst, hepatitis or liver failure, peptic ulcer disease, bowel obstruction, and vascular causes like mesenteric ischemia.
What is a critical pertinent negative for acute cholecystitis?
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.
What is the next step if ultrasound findings are inconclusive but suspicion for biliary disease remains high?
Consider magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) for further evaluation of biliary obstruction.
In what instance is elevated direct bilirubin assoicated with cholecystitis and what is this sign?
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.
How is biliary colic managed after ruling out severe conditions?
Supportive care with pain management, bowel rest, IV fluids, and potential elective cholecystectomy for recurrent symptoms.
What is the goal of management for patients with cholecystitis?
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.
Patients with suspected acute cholangitis because of the findings of right upper quadrant abdominal pain, fever, and jaundice (Charcot Triad), will require an emergent … ?
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.
A 44-year-old woman presents to the emergency department with abdominal pain. The abdominal pain started two days ago, and the patient woke up this morning with chills and uncontrollable shaking. Past medical history is unremarkable. Temperature is 38.6 °C (101.5 °F), pulse is 120/min, blood pressure is 78/45 mmHg, respirations are 20/min, and SpO is 99% on room air. Physical examination reveals an ill-appearing patient. There is moderate right upper quadrant tenderness to palpation. Abdominal ultrasound shows a common bile duct measuring 10 mm and a stone within the duct. Gastroenterology is consulted and ERCP (endoscopic retrograde cholangiopancreatography) is scheduled. The patient is given 3500 mL of IV normal saline and a dose of IV piperacillin-tazobactam. Repeat blood pressure after fluids are administered is 85/49 mmHg. Which of the following is the most appropriate next step in management?
A) Change piperacillin-tazobactam to ciprofloxacin plus metronidazole
B) Start norepinephrine infusion
C) Give another liter of normal saline
D) Cancel ERCP and perform open surgical drainage
E) Repeat the blood pressure reading in 30 minutes
Choledocholithiasis (stone in the common bile duct) should be treated with urgent ERCP followed by cholecystectomy. If acute cholangitis is present, patients should be started on IV antibiotics and IV fluids, and an emergent ERCP should be performed. IV piperacillin-tazobactam is the appropriate antibiotics for patients with suspected cholangitis. An ERCP is the gold standard of treatment for cholangitis. In patients who cannot undergo ERCP or those who have had an unsuccessful ERCP, percutaneous biliary drain placement can be done. ERCP is faster, easier, and safer than surgery for this patient and should be performed. Patients with septic shock from acute cholangitis should receive vasopressors and will often improve quickly after a successful ERCP. This patient presenting with right upper quadrant abdominal pain was found to have a dilated common bile duct (CBD) on ultrasound with a stone present in the CBD (choledocholithiasis). Given the presence of fever, this patient likely has acute (ascending) cholangitis, which is inflammation of the biliary duct system from bacterial infection. She has developed hypotension and septic shock that is unresponsive to IV fluids, and therefore she should be started on a norepinephrine infusion. Risk factors for the development of choledocholithiasis include female sex, increasing age, and obesity. Ultrasound is sensitive for detecting CBD stones, but if there is still uncertainty, then an MRCP (magnetic resonance cholangiopancreatography) can be performed. Patients with choledocholithiasis need ERCP (endoscopic retrograde cholangiopancreatography) to extract the stone, and eventual cholecystectomy. If left untreated, choledocholithiasis can cause acute cholangitis, as seen in this patient, or acute biliary pancreatitis. Patients who develop acute cholangitis need emergent ERCP, IV antibiotics, and IV fluid resuscitation. This patient has already received 3.5 liters of IV fluid and is still hypotensive. It is highly unlikely that another liter of fluid will dramatically improve her blood pressure. Patients with sepsis and hypotension refractory to ≥30 mL/kg of IV fluid have septic shock and need to be started on vasopressors. Patients can decompensate quickly and develop septic shock which can be defined as sepsis with hypotension refractory to fluid resuscitation. Patients with septic shock (hypotension despite IV fluids) should be started on vasopressors (e.g. norepinephrine). If ERCP cannot be performed, a biliary duct drain can be placed percutaneously by radiology, or less commonly, it can be put in place during open surgery.
The preferred intravenous (IV) antibiotic regimen for acute cholangitis is …?
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.
A palpable gallbladder in the presence of jaundice is a positive ________ sign.
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.
