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Biliary colic, also referred to as a gallbladder attack or gallstone attack, is when pain occurs due to a gallstone briefly blocking the bile duct. Generally, the discomfort is in the right upper portion of the abdomen, and it can spread to the shoulder. Pain generally lasts from one to a few hours. Often, it transpires after eating a heavy meal, or throughout the night. Repeated attacks are common.
Gallstone formation happens from the precipitation of crystals that assemble and come together forming stones. The most common form is cholesterol gallstones. Other forms include calcium, bilirubin, pigment, and mixed gallstones.Other ailments that produce related or comparable symptoms which include, stomach ulcers, appendicitis gastroesophageal reflux disease, and pancreatitis
Treatment for gallbladder attacks is commonly involved surgery to remove the gallbladder. This can be either implemented through small incisions or through a single larger incision. Open surgery through a larger incision is associated with more complications than surgery through small incisions. Surgery is typically done under general anesthesia. In those who are not able to undergo surgery, it may be best to leverage medicine to try to diffuse the stones or shock wave lithotripsy may be tried. As of 2017, it is not clear whether surgery is indicated for everyone with biliary colic.
In the developed world, 10-15% of adults have gallstones.Of those with gallstones, biliary colic occurs in 1–4% each year. Nearly 30% of people have further problems related to gallstones in the year following an attack.About 15% of people with biliary colic eventually develop inflammation of the gallbladder if not treated. Other complications include inflammation of the pancreas.
Pain is the most prevalent symptom. It is usually characterized by acute right upper quadrant pain that radiates to the right shoulder, or less commonly, behind the breastbone. Nausea and vomiting can be with biliary colic. People may also suffer from pain that is induced by a fatty meal and the symptom of indigestion. The pain often persists longer than 30 minutes, up to a few hours. Patients usually have normal vital signs with biliary colic, whereas patients with cholecystitis are usually febrile and iller appearing. Lab studies that should be ordered include a complete blood count, liver function tests, and lipase. In biliary colic, lab findings are usually within normal limits. Alanine aminotransferase and aspartate transaminase are usually suggestive of liver disease whereas elevation of bilirubin and alkaline phosphatase suggests common bile duct obstruction. Pancreatitis should be recognized as an option if the lipase value is heightened; gallstone disease is the primary cause of pancreatitis.
Biliary pain is most commonly triggered by the interference of the the cystic duct or a common bile duct by a gallstone. However, the presence of gallstones is a prevalent incidental finding and does not always require treatment, in the lack of identifiable disease. Furthermore, biliary pain may be linked with functional disorders of the biliary tract, so-called acalculous biliary pain (pain without stones), and can even be revealed in patients after -cholecystectomy (removal of the gallbladder), probably as a result of dysfunction of the biliary tree and the sphincter of Oddi. Acute episodes of biliary pain may be induced or exacerbated by certain foods, most commonly those high in fat.
Cholesterol gallstone formation risk factors include age, female sex, family history, race, pregnancy, parity, obesity, birth control, diabetes mellitus, cirrhosis, prolonged fasting, rapid weight loss, total parenteral nutrition, ileal disease and impaired gallbladder emptying.
Patients that have gallstones and biliary colic are at increased risk for complications, including cholecystitis. Complications from gallstone disease are 0.3% per year, and therefore prophylactic cholecystectomy is rarely indicated unless part of a special population that includes porcelain gallbladder, individuals eligible for an organ transplant, diabetics and those with sickle cell anemia.
Diagnosis is guided by the person’s displaying symptoms and laboratory findings. The gold standard imaging modality for the appearance of gallstones is an ultrasound of the right upper quadrant. There are several causes for this choice, including no exposure to radiation, low cost, and availability in the city, urban, and rural hospitals. Gallstones are identified with a specificity and sensitivity of greater than 95% with ultrasound. Further signs on ultrasound may suggest cholecystitis or choledocholithiasis. Computed Topography (CT) is not indicated when investigating for gallbladder disease as 60% of stones are not radiopaque. CT should only be utilized if another intraabdominal pathology exists or the diagnosis is uncertain.Endoscopic retrograde cholangiopancreatography (ERCP) should be used only if lab tests suggest the existence of a gallstone in the bile duct. ERCP is then both diagnostic and therapeutic.
Initial management encompasses the relief of symptoms and correcting electrolyte and fluid imbalance that may occur with vomiting.Antiemetics, such as dimenhydrinate, are used to treat nausea. Pain can be managed with anti-inflammatories, NSAIDs such as diclofenac or ketorolac. Opioids, such as morphine, less commonly may be used. NSAIDs are more or less comparable to opiates.Hyoscine butyl bromide, an antispasmodic, is also indicated in biliary colic.
In biliary colic, the risk of infection is minimum, and therefore antibiotics are not required.Presence of infection indicates cholecystitis.
It is unclear whether those encountering a gallstone attack should receive surgical treatment or not. The scientific basis to assess whether surgery outperformed other treatment was insufficient and better studies were needed as of an SBU report in 2017. Treatment of biliary colic is directed by the underlying cause. The presence of gallstones, usually visualized by ultrasound, generally necessitates a surgical treatment (removal of the gallbladder, typically via laparoscopy). Removal of the gallbladder with surgery, recognized as a cholecystectomy, is the comprehensive surgical treatment for biliary colic. A 2013 Cochrane review found tentative evidence to suggest that early gallbladder removal may be better than delayed removal.. Early laparoscopic cholecystectomy happens within 72 hours of diagnosis In a Cochrane review that evaluated receiving early versus delayed surgery; they found that 23% of those who waited on average four months ended up in the hospital for complications, compared to none with early intervention with surgery.Early intervention has other benefits including a reduced number of visits to the emergency department, fewer conversions to an open surgery, less operating time required, reduced time in hospital postoperatively. The Swedish agency SBU estimated in 2017 that increasing acute phase surgeries could free multiple in-hospital days per patient and would additionally spare pain and suffering in wait of receiving an operation. The assessment found that those with acute inflammation of the gallbladder can be surgically managed in the acute phase, within a several days of symptom appearance, without increasing the risk for complications (opposed to when the surgery is done later in an asymptomatic stage).
The presence of gallstones can lead to inflammation of the gallbladder (cholecystitis) or the biliary tree (cholangitis) or acute swelling of the pancreas (pancreatitis). Unusually, a gallstone can become affected in the ileocecal valve that connects the caecum and the ileum, causing gallstone ileus (mechanical ileus).
Complications from delayed surgery include pancreatitis, empyema, and perforation of the gallbladder, cholecystitis, cholangitis, and obstructive jaundice.
Biliary pain in the absence of gallstones, known as a postcholecystectomy syndrome, may severely impact the patient’s quality of life, even in the absence of disease progression.