What is Biliary Colic?
Biliary colic is a common condition caused by a stone blocking the cystic duct or common bile duct, which are part of the system that helps the digestion of fats in our body. The term “colic” usually refers to a type of pain that comes and goes, often after eating a large, fatty meal which causes the gallbladder to contract. However, the pain from biliary colic is usually constant, not fluctuating.
The main treatment for biliary colic is surgery to remove the gallbladder, usually performed with a technique that involves making small incisions, known as laparoscopic surgery. Normally, this condition isn’t serious enough to require staying in the hospital.
Biliary colic typically describes the pain from a temporary blockage in the biliary system which eventually clears by itself. However, if a stone completely blocks the biliary system or the blockage lasts for a long time, this can lead to inflammation of the gallbladder or bile ducts (known as cholecystitis or cholangitis), resulting in constant, increasing pain.
What Causes Biliary Colic?
Gallstones are hard pieces that are created in the gallbladder. They can be made from cholesterol (a type of fat) or bilirubin (a waste material produced by the liver). These gallstones might stay in the gallbladder, without causing any pain or symptoms. However, they could also move into ducts leading away from the gallbladder, where they might get stuck. This typically causes pain when the gallbladder squeezes as a reaction to a meal high in fat.
To help explain, after a fatty meal, the gallbladder tries to help your belly break down the fats by squeezing out a substance called bile. If a gallstone is blocking the way, this can cause a lot of pain. Sometimes, gallstones don’t make a person feel sick and are just found by chance during a check-up or scan. This is called asymptomatic cholelithiasis. If this is the case, usually no medical or surgical treatment is needed and no further follow-ups are necessary.
However, if a person experiences symptoms like pain, nausea, or vomiting, usually on the upper right side of their belly, they might have symptomatic cholelithiasis which requires a check-up with a surgeon. If the pain goes away on its own, like if the gallstone makes its way into the digestive tract or falls back into the gallbladder after getting stuck in a duct, this is termed as biliary colic.
Risk Factors and Frequency for Biliary Colic
It is estimated that about 10% to 20% of adults have gallstones, but only 1% to 3% of people with gallstones actually show symptoms. In the United States, around 500,000 people need their gallbladder removed due to different biliary diseases. Biliary colic, a type of gallbladder disease, is more common in women because the estrogen hormone plays a role in the formation of gallstones.
People who are obese or have high cholesterol run a higher risk of getting biliary colic and gallbladder disease, because in the United States most gallstones are made of cholesterol. However, in developing countries, a different type of gallstone, often called pigmented stones are more common. These stones are made from a substance called bilirubin and are usually linked to blood disorders and infections in the biliary system (the liver, gallbladder and bile ducts).
All types of gallstones can cause biliary colic. If a stone blocks the cystic duct or the bile duct (which carry bile from the liver and gallbladder to the small intestine), it might develop into cholecystitis (an inflammation of the gallbladder) or cholangitis (an infection of the bile duct).
Signs and Symptoms of Biliary Colic
Biliary colic is a condition that features pain in the upper right part of the belly. This pain typically comes and goes, particularly after meals, which is why it’s often referred to as ‘colic’. Apart from pain, some people may also experience nausea and vomiting. Despite these discomforts, people with biliary colic usually don’t show abnormal vital readings like fever, fast heartbeat, or low blood pressure, which are common in more severe conditions such as acute cholecystitis or cholangitis.
On a physical exam, these patients usually have tenderness in the upper right quadrant or the upper middle part of the abdomen. They seldom exhibit abdominal bloating or extreme pain when the abdomen is released quickly after being pressed (rebound tenderness). Jaundice, or yellowing of the skin, isn’t commonly seen unless the common bile duct is obstructed, which can show a high level of direct bilirubin in the blood. This could suggest a more serious blockage and might indicate the possibility of cholangitis rather than biliary colic.
People at higher risk for biliary colic include:
- Older adults
- Pregnant women
- People of North European descent
- Those who have recently lost weight
- Those who are obese
- Liver transplant recipients
Testing for Biliary Colic
If your doctor needs to determine whether you have a severe gallbladder problem such as acute cholecystitis or cholangitis, they will ask for lab tests like a complete blood count (CBC) and a metabolic panel that includes liver function tests. These tests are crucial because if your white blood cell count is raised, it could suggest acute cholecystitis or cholangitis. Similarly, if liver tests like direct bilirubin, AST, ALT, ALP, and GGT are high, this might mean that there’s a stone or a blockage in your common bile duct. Gallstones inside the gallbladder or cystic duct usually don’t cause abnormal results in these tests unless the condition has advanced from biliary colic to cholecystitis where high white cell count might be seen.
More investigations are needed for a thorough evaluation of suspected issues with the gallbladder, and this is where imaging comes into play. Doctors typically request a “RUQ abdominal ultrasound” which is an imaging technique used to examine the upper right side of your abdomen, primarily focusing on your gallbladder. Another test known as “HIDA scan” can be used to evaluate if there’s inflammation in the gallbladder (acute or chronic cholecystitis), and it can also check for biliary dyskinesia, a condition where the gallbladder is not emptying as well as it should.
While a CT scan of the abdomen is less efficient at detecting stones in the gallbladder compared to an ultrasound, it’s frequently used by emergency room doctors when a patient comes in with severe non-specific abdominal pain. Findings from the CT scan may reveal the presence of gallstones. If a more detailed view of the bile duct system is required, then an MRCP may be ordered especially when checking for stones in the bile ducts. In cases where all other imaging isn’t conclusive, an ERCP can be done. It’s an endoscopic procedure that helps to identify stones in the common bile duct, and it can also facilitate removal of the stones if necessary.
Different imaging techniques will show different things. For example, typical findings on an “RUQ abdominal ultrasound” for biliary colic (pain caused by the blockage of the bile flow due to gallstones) include gallstones of different sizes or shadows of stones. But when there’s fluid around your gallbladder, a distended gallbladder (swollen and filled with bile), and a thicker wall of your gallbladder (more than 0.4 cm), these are more suggestive of acute cholecystitis, which is inflammation of your gallbladder.
Treatment Options for Biliary Colic
Biliary colic is usually treated by surgery. Biliary colic is a type of stomach pain caused by gallstones in the bile ducts. Non-surgical treatment primarily consists of following a diet low in fat, along with medications to control nausea and pain. Even though this can help manage the symptoms, it doesn’t entirely eliminate the problem as most patients have multiple gallstones, increasing their risk of experiencing biliary colic again. Antibiotics are not required for biliary colic because it’s not caused by an infection.
Oral medication, like ursodeoxycholic acid, has been used to dissolve gallstones. Still, surgery to remove the gallbladder (known as laparoscopic cholecystectomy) is the most effective treatment. For patients who aren’t good candidates for surgery, a procedure called extracorporeal shockwave lithotripsy could be considered. This involves using soundwaves to break up the gallstones, but the gallstones might reoccur. Open surgery (open cholecystectomy) is less common and is typically only used for patients who are not suitable for laparoscopic surgery.
Another procedure called endoscopic retrograde cholangiopancreatography (ERCP) can also be performed. This procedure helps doctors visualize the bile ducts and remove stones that might be causing problems.
Not all patients with biliary colic need to stay in the hospital. Many can be treated at home with a low-fat diet, pain control medications, and anti-nausea medications. Meanwhile, a laparoscopic cholecystectomy can be scheduled within a reasonable time frame. If a patient’s stomach pain is severe, admission to a hospital and immediate surgical intervention may be needed. Additionally, patients with large gallstones (greater than 1 cm) or those who can’t consume anything orally, even liquids, might also need hospitalization and quicker surgical intervention since they are at a high risk of developing acute cholecystitis, a condition where the gallbladder becomes inflamed.
What else can Biliary Colic be?
Here are some conditions that could be confused with the disease the doctors are trying to diagnose:
- Hepatitis (an inflammation of the liver)
- Cholangitis (an inflammation of the bile duct)
- Mesenteric ischemia (lack of blood flow to the intestines)
- Pancreatitis (an inflammation of the pancreas)
- Renal calculi (also known as kidney stones)
- Viral or bacterial gastroenteritis (an infection causing irritation and inflammation in your gut)
- Biliary dyskinesia (a disorder affecting the bile ducts)
Possible Complications When Diagnosed with Biliary Colic
- Inflammation of the pancreas
- Infection in the bile duct
- Rupture of the gallbladder
Recovery from Biliary Colic
Cholecystectomy, which is a surgical procedure to remove the gallbladder, is generally done as a planned procedure for a condition known as biliary colic. This typically results in a very smooth recovery after the surgery. Biliary colic, in simple terms, is a condition where you get bouts of pain in your abdomen due to the gallbladder stones and it usually happens before any serious swelling or inflammation, which is cholecystitis, sets in. Therefore, the surgery to remove the gallbladder tends to be easier in this scenario.
Often, patients can even go home the same day or just after one day in the hospital, provided they can take in enough food and drink by mouth and their pain is well managed.
Preventing Biliary Colic
If a patient with biliary colic, which is a type of severe stomach pain caused by gallstones, decides to manage their condition without surgery, then it’s essential for them to understand the signs of a condition called cholecystitis. They should be informed that if their stomach pain lasts longer than a few hours, gets a lot worse, or if they start to have a fever, they should seek immediate medical attention. Patients should know that they are at a high risk for developing a trapped gallstone, which can lead to dangerous infections like cholecystitis or cholangitis. Cholecystitis is inflammation of the gallbladder and cholangitis is inflammation of the bile ducts. They should also be aware that eating fatty foods can cause the gallbladder to tighten and can bring on these severe stomach pains.
