Updated: 6/5/2019

Cholelithiasis and Biliary Colic

Topic
Review Topic
0
0
Questions
10
0
0
Evidence
7
0
0
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
 

Please rate topic.

Average 4.9 of 8 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (10)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(M2.GI.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? Review Topic

QID: 107019
FIGURES:
1

HIDA scan

6%

(1/18)

2

Endoscopic retrograde cholangiopancreatography

0%

(0/18)

3

Exploratory laparoscopy

0%

(0/18)

4

Abdominal CT

0%

(0/18)

5

Discharge

89%

(16/18)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(M2.GI.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? Review Topic

QID: 104832
FIGURES:
1

Viscous distension of gallbladder

65%

(13/20)

2

Inflammation of gallbladder

15%

(3/20)

3

Inflammation of common bile duct

0%

(0/20)

4

Viscous distension of cystic duct

15%

(3/20)

5

Inflammation of cystic duct

0%

(0/20)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M2.GI.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? Review Topic

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)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
ARTICLES (9)
Topic COMMENTS (11)
Private Note