Updated: 12/21/2019

Cholelithiasis and Biliary Colic

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Questions
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Topic
Snapshot
  • A 46-year-old woman presents to her primary care physician for recurrent right upper quadrant pain. She reports 30-minute episodes of abdominal pain after eating meals, especially with fast food meals. She has not had any fevers or chills, and her episodes always resolve. Her past medical history includes hyperlipidemia, morbid obesity, and polycystic ovarian syndrome, for which she takes oral contraceptives. Her physician orders a right upper quadrant ultrasound, which shows gallstones without any wall thickening. Her physician recommends conservative measures for now, including dietary changes.
Introduction
  • Clinical definition
    • cholelithiasis
      • stones in gallbladder are cholesterol or pigment stones
    • biliary colic
      • right upper quadrant abdominal pain following meals, usually associated with nausea and vomiting that self-resolves
      • occurs particularly after fatty or heavy meals (secondary to cholecystokinin (CCK) release) or at night 
  • Epidemiology
    • demographics
      • female > male
      • adults
    • risk factors
      • cholesterol stones (most common)
        • F’s
          • Fat
          • Female
          • Forty
          • Fertile
        • impaired gallbladder emptying  
          • total parenteral nutrition
          • starvation
          • diabetes
        • biliary stasis
          • rapid weight loss
        • Native American heritage
      • pigment stones
        • cirrhosis
        • biliary stasis
        • chronic hemolysis
  • Pathogenesis
    • cholesterol saturation can cause impaired gallbladder motility
    • gallstones can lead to mechanical obstruction of biliary tract and cause bacterial overgrowth
  • Associated conditions
    • acute cholecystitis
    • ascending cholangitis
    • acute pancreatitis
    • gallstone ileus
Presentation
  • Symptoms
    • cholelithiasis
      • may be asymptomatic
    • biliary colic
      • colicky pain in right upper quadrant
      • may radiate to the right shoulder
      • triggered by fatty or heavy foods
      • episodes self-resolve
Studies
  • Diagnostic testing
    • diagnostic approach
      • gallstones may be found incidentally on abdominal imaging
    • imaging
      • right upper quadrant ultrasound
        • findings
          • gallstones
      • magnetic resonance cholangiopancreatography (MRCP)
        • indication
          • ultrasound results are equivocal
      • endoscopic retrograde cholangiopancreatography (ERCP)
        • indication
          • both diagnostic and therapeutic
          • if intervention is indicated
    • studies
      • alkaline phosphatase and bilirubin may be elevated but only mildly
      • amylase
        • to assess for gallstone pancreatitis
  • Diagnostic criteria
    • gallstones on imaging
Differential
  • Peptic ulcer disease
    • distinguishing factors
      • epigastric gnawing pain that may improve with meals
      • ultrasound will show no signs of biliary disease
  • Sphincter of Oddi dysfunction
    • distinguishing factors
      • presents similarly to biliary colic
      • diagnosed with manometry
      • treated with sphincterotomy via ERCP
Treatment
  • Management approach
    • incidental asymptomatic gallstones do not require any treatment   
    • antibiotics are not needed for simple cholelithiasis and biliary colic
  • First-line
    • supportive care
      • analgesia
        • NSAIDs
      • diet
        • avoid fatty foods that trigger biliary colic
      • rehydration
    • elective cholecystectomy
      • indications
        • symptomatic cholelithiasis
        • patients at risk for cholangiocarcinoma
          • Native American heritage
          • porcelain gallbladder
          • gallstone pancreatitis
  • Second-line
    • ursodeoxycholic acid
      • indication
        • patients unwilling or contraindicated to undergo cholecystectomy
        • can be used as prophylaxis
        • mechanism
          • dissolves gallstones
Complications
  • Secondary infections

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(M2.GI.15.25) A 42-year-old female with a history of obesity, diabetes, asthma, and hypertension presents to her primary care physician for a follow-up visit after being seen in the ED 1 week ago. She had presented to the ED with urinary urgency, dysuria, increased frequency and was diagnosed with a urinary tract infection, and ultimately discharged on appropriate antibiotic therapy. During her ED workup, an abdominal ultrasound was obtained which is demonstrated in Figure A. She currently denies a history of abdominal pain, nausea and vomiting, early satiety or any other abdominal complaints. She states that apart from her urinary tract infection, which has now successfully been resolved, she feels well. What is the appropriate management for the incidental findings observed in Figure A?

QID: 104816
FIGURES:
1

Laparoscopic cholecystectomy

6%

(1/18)

2

Open cholecystectomy

0%

(0/18)

3

Ursodeoxycholic acid

6%

(1/18)

4

No further management at this time

83%

(15/18)

5

Endoscopic retrograde cholangiopancreatography

0%

(0/18)

M 7 B

Select Answer to see Preferred Response

(M2.GI.15.41) A 42-year-old woman presents to the emergency department with severe abdominal pain. She states the pain is 9/10 in severity, is sharp in quality, located primarily on her right side, and seems to radiate to her right shoulder blade. She states that she has had similar pain in the past and it always seems to be caused by ingestion of a large meal. On exam, the patient is well appearing and her vitals are shown as: T: 36 deg C, HR: 78 bpm, BP: 130/80 mmHg, RR: 10, SaO2: 100%. A CBC, BMP, and liver function tests are ordered, and all are within normal limits. The emergency physician performs an emergency medicine bedside ultrasound (EMBU) and observes the findings shown in Figure A. What is the cause of this patient's pain?

QID: 104832
FIGURES:
1

Viscous distension of gallbladder

68%

(15/22)

2

Inflammation of gallbladder

14%

(3/22)

3

Inflammation of common bile duct

0%

(0/22)

4

Viscous distension of cystic duct

14%

(3/22)

5

Inflammation of cystic duct

0%

(0/22)

M 5 B

Select Answer to see Preferred Response

(M2.GI.15.4816) A 42-year-old obese female presents to the emergency room requesting a pregnancy test. On exam, blood pressure is 135/80 mmHg, heart rate is 79 bpm, respiratory rate is 18 bpm, and she is afebrile. Urine pregnancy test is found to be positive, and an abdominal ultrasound is ordered for staging. The technician inadvertently also scans the patient's right upper quadrant, and an image from this study is shown in Figure A. She denies present or history of episodic right upper quadrant pain. Which of the following is the next best step?

QID: 107019
FIGURES:
1

HIDA scan

5%

(1/20)

2

Endoscopic retrograde cholangiopancreatography

5%

(1/20)

3

Exploratory laparoscopy

0%

(0/20)

4

Abdominal CT

0%

(0/20)

5

Discharge

80%

(16/20)

M 7 D

Select Answer to see Preferred Response

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Evidence (9)
EXPERT COMMENTS (11)
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