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Biliary Colic

Introduction

Biliary colic: pain produced by stones intermittently obstructing the cystic duct
Cholelithiasis: presence of gallstones in the gallbladder
Cholecystitis: inflammation of the gallbladder, usually due to infection
Choledocolithiasis: presence of gallstones in the common bile duct
Cholangitis: inflammation of the common bile duct, usually due to infection

Bile drains from the liver into the right and left hepatic ducts which fuse to become the common hepatic duct. This is joined distally by the cystic duct from the gallbladder, to become the common bile duct.

The common bile duct then runs behind the duodenum, through the head of the pancreas, and unites with the pancreatic duct to form an area called the Ampulla of Vater. Here, there’s a small sphincter called the sphincter of Oddi which surrounds the major duodenal papilla and prevents reflux of duodenal contents.

While bile is made by the liver, it’s stored and concentrated by the gallbladder. When fatty foods are eaten, the duodenum releases a hormone called . This contracts the gall bladder and squeezes bile into the intestines.

Blood tests are used to exclude other differentials:

FBC: should be normal while elevated white cells are more suggestive of acute cholecystitis.
Lipase levels: to exclude pancreatitis.
LFT: often normal

Imaging is more useful for diagnosis. Abdominal ultrasound can show a stone in the gallbladder. One good indicator is known as acoustic shadowing. This occurs when transmitted sound waves are reflected after hitting a stone, causing a blacked-out imaging artefact.

Non-operatively:

The biliary colic can be treated with analgesia.

One key takeaway is that NSAIDs and opioids have similar analgesic efficacy for this type of pain. Paracetamol is also something to consider.

Operatively:

A laparoscopic cholecystectomy is the definitive treatment for attacks of biliary colic. This can be done as an elective day case unless the patient’s clinical condition warrants a hospital stay.

Patients are frequently put on a low-fat diet initially or whilst awaiting operation.

Its important to note this operation may occasionally turn into an open procedure.

Don’t forget the unflattering but time-honoured mnemonic that’s helped students remember the risk factors of gallstones for years.

The 4 F’s stand for:

Female
Fat
Forty
Fair skinned