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Updated: Dec 14 2021

Cholelithiasis and Biliary Colic

Images tree - moises dominguez 1.jpg
  • 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
    • Associated conditions
      • acute cholecystitis
      • ascending cholangitis
      • acute pancreatitis
      • gallstone ileus
  • 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
  • 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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