Biliary Colic

Aka: Biliary Colic

1. Symptoms
   1. Abdominal Pain characteristics
      1. RUQ Abdominal Pain or Epigastric Abdominal Pain
      2. Dull visceral ache
      3. Poorly localized discomfort
      4. Pain radiates to right posterior Shoulder or Scapula
   2. Abdominal Pain timing:
      1. Occurs suddenly 30-60 minutes after a meal
         1. Normal meal
         2. Large meal after a fast
         3. Fatty meal
      2. Increasing frequency and intensity of attacks
      3. Pain lasts for 1-6 hours
      4. Intermittent "colicky" exacerbations of pain
      5. Mild abdominal aching for 1-2 days after attack
   3. Associated symptoms
      1. Nausea and Vomiting
      2. No Fever or chills (see differential diagnosis)
2. Signs
   1. RUQ abdominal tenderness
   2. No signs of peritoneal irritation
   3. Dehydration from protracted Vomiting
3. Differential Diagnosis
   1. Acute Cholecystitis
   2. Cholangitis
   3. Pancreatitis
4. Labs
   1. Complete Blood Count usually normal
   2. Mild elevation of Liver Function Tests
      1. Bilirubin slightly elevated
      2. Alkaline Phosphatase slightly elevated
   3. Pancreatic enzyme tests normal
      1. Amylase normal
      2. Lipase normal
   4. Urinalysis normal
   5. HCG normal
5. Radiology
   1. XRay Abdomen
      1. Test Sensitivity: 10-20% for Gallstones
   2. Chest XRay normal
   3. RUQ Ultrasound
      1. Test Sensitivity: 95% for Gallstones
   4. Oral Cholecystography
      1. Indicated for normal or equivocal Ultrasound
6. Management
   1. Laparoscopic Cholecystectomy
      1. Preferred option
   2. Antispasmodic
      1. Glycopyrrolate (Robinul)
         1. Parenteral: 0.1 to 0.2 mg IV or IM
         2. Oral: 1.0 to 2.0 mg PO bid-tid
   3. Analgesic
      1. Meperidine (Demerol)
         1. Less sphincter of Oddi spasm than morphine
      2. Ketorlac (Toradol)
         1. Relieves pain of gallbladder distention
         2. Not as effective if infection present
   4. Antiemetics
      1. Promethazine (Phenergan)
   5. Nasogastric Suction
      1. Indicated for protracted Vomiting
   6. Alternatives in non-surgical candidates
      1. Bile Acid Oral Dissolution Therapy