Biliary colic

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Biliary colic , also known as gallbladder attack or gallstone attack , is when pain occurs because gallstones block bile ducts temporarily. Usually, the pain is in the upper right part of the abdomen, and can spread to the shoulders. Pain usually lasts from one to several hours. Often, it happens after eating heavy meals, or at night. Repeated attacks are common.

Gallstone formations occur from the precipitation of crystals that aggregate to form stones. The most common form is cholesterol gallstones. Other forms include calcium, bilirubin, pigment, and mixed gall stones. Other conditions that produce similar symptoms include appendicitis, heartburn, pancreatitis, and gastroesophageal reflux disease.

Treatment for gall bladder attacks is usually surgery to remove the gallbladder. This can be done through a small incision or through a larger incision. Open surgery through larger incisions is associated with more complications than surgery through small incisions. Surgery is usually performed under general anesthesia. In those who can not undergo surgery, drugs to try to dissolve stones or lithotripsy shock waves can be tried. By 2017, it is unclear whether surgery is indicated for everyone with biliary colic.

In developed countries, 10-15% of adults have gallstones. Of those with gallstones, biliary colic occurs in 1-4% every year. Nearly 30% of people have further problems associated with gallstones in the following year after the attack. About 15% of people with biliary colic end up with gall bladder inflammation if left untreated. Other complications include pancreatic inflammation.

Video Biliary colic

Signs and symptoms

Pain is the most common symptom. Usually described as a right upper quadrant pain radiating to the right shoulder, or less commonly, behind the breastbone. Nausea and vomiting can be associated with biliary colic. Individuals may also present with induced pain after eating fatty and indigestion symptoms. The pain often lasts more than 30 minutes, up to several hours. Patients usually have normal vital signs with biliary colic, whereas patients with cholecystitis usually have a fever and more pain appears. Laboratory studies to be ordered include a complete blood count, liver function tests and lipase. In biliary colic, laboratory findings are usually within normal limits. Alanine aminotransferase and aspartate transaminase are usually suggestive of liver disease whereas elevation of bilirubin and alkaline phosphatase exhibits general bile duct obstruction. Pancreatitis should be considered if the lipase value is increased; gallstone disease is the main cause of pancreatitis.

Maps Biliary colic

Cause

Bilateral pain is most commonly caused by bile duct obstruction of a communist or cystic duct by gallstones. However, the presence of gallstones is a frequent and often incidental finding that does not necessarily require treatment, in the absence of an identifiable disease. In addition, biliary pain may be associated with functional impairment of the bile ducts, called biliary pain akalkulus (pain without stones), and can even be found in post-cholecystectomy patients, possibly as a result of biliary tree dysfunction and Oddi sphincter. Acute episodes of biliary pain may be induced or aggravated by certain foods, most often those that are high in fat.

Risk factors

Risk factors for cholesterol gallstone formation include age, female gender, family history, race, pregnancy, parity, obesity, birth control, diabetes mellitus, cirrhosis, prolonged fasting, rapid weight loss, total parenteral nutrition, ileal disease and impaired gastric emptying bile.

Patients who have gallstones and biliary colic are at increased risk for complications, including cholecystitis. The complications of gallstone disease are 0.3% per year and therefore prophylactic cholecystectomy is rarely indicated except for part of a special population that includes a porcelain gallbladder, individuals eligible for organ transplants, diabetics and those with sickle cell anemia.

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Diagnosis

The diagnosis is guided by the symptoms of the person present and the laboratory findings. The gold standard imaging modalities for the presence of gallstones are the ultrasound of the upper right quadrant. There are many reasons for this option, including no radiation exposure, low cost, and availability in urban, rural, and rural hospitals. Gallstones are detected with specificity and sensitivity of more than 95% with ultrasound. Further signs of ultrasound may show cholecystitis or choledocholithiasis. Computed Topography (CT) is not indicated when investigating gallbladder disease because 60% of stones are not radiopak. CT should only be used if there are other intraabdominal pathologies or an uncertain diagnosis. Endoscopic retrograde cholangiopancreatography (ERCP) should be used only if laboratory tests indicate the presence of gallstones in the bile ducts. ERCP is then diagnostic and therapeutic.

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Management

Drugs

Initial management includes relieving symptoms and correcting electrolyte imbalances and fluids that may occur with vomiting. Antiemetics, such as dimenhydrinate, are used to treat nausea. Pain can be treated with anti-inflammation, NSAIDs such as ketorolac or diclofenac. Opioids, such as morphine, are less commonly used. NSAIDs are roughly equivalent to opioids. Hyoscine butylbromide, antispasmodic, is also indicated in biliary colic.

In biliary colic, the risk of infection is minimal and therefore antibiotics are not necessary. The presence of infection indicates cholecystitis.

Surgery

It is unclear whether those who have gallstones attack should receive surgical treatment or not. The scientific basis for assessing whether surgery outperforms other treatments is inadequate and better research is needed on the SBU report by 2017. Treatment of biliary colic is dictated by the underlying cause. The presence of gallstones, usually visualized with ultrasound, generally requires surgical treatment (removal of the gallbladder, usually through laparoscopy). The removal of the gall bladder by surgery, known as cholecystectomy, is the definitive surgical treatment for biliary colic. The 2013 Cochrane review found tentative evidence suggesting that early removal of the gall bladder may be better than delayed deletion. Early laparoscopic cholescystectomy occurs within 72 hours after diagnosis. In a Cochrane review evaluating receiving early surgery versus pending, they found that 23% of those who waited for an average of 4 months ended up in hospital for complications, compared with none at all with early surgical intervention. Early intervention has other advantages including reducing the number of visits to the emergency department, less conversion to open surgery, less necessary surgery time, reduced hospital post-operative time. The Swedish Agency of the SBU estimates in 2017 that an increase in acute phase surgery can free up several days in the hospital per patient and will also relieve pain and suffering waiting to receive surgery. The report found that those with acute gall bladder inflammation may undergo surgery in the acute phase, within days of symptom debut, without increasing the risk of complications (compared when surgery is done later in the asymptomatic stage).

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Complications

The presence of gallstones can cause inflammation of the gallbladder (cholecystitis) or biliary tree (kolangitis) or acute inflammation of the pancreas (pancreatitis). Rarely, gallstones can affect the ileocecal valve that connects the cecum and ileum, causing gallstones ileus (mechanical ileus).

Complications of delayed surgery include pancreatitis, empyema, and gallbladder perforation, cholecystitis, cholangitis, and obstructive jaundice.

Bilateral pain in the absence of gallstones, known as postcholecystectomy syndrome, can greatly affect the quality of life of patients, even in the absence of disease progression.