Case 052: Biliary Colic

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Case 052: Biliary colic
Author: John Wong MBChB, FRCSEd

David C Chung MD, FRCPC
Affiliation: The Chinese University of Hong Kong
Mrs. LSJ was a 41 year old mother who presented to her doctor because she
experienced an episode of epigastric pain 3 hours after her evening meal of fish, tofu,
vegetable, and brown rice the night before. She described the attack as sudden
onset of continuous pain of increasing intensity over 10 to 15 minutes and lasted for
more than 2 hours. It felt like someone was pushing a fist against her stomach and
there was a vague discomfort around her right shoulder as well. This was her first
attack. She thought it was due to acid indigestion and took 2 antacid tablets without
relief. Relief came only later when the pain eased off gradually after she applied a
heating pad to her abdomen. She admitted to having been healthy all her life; the
only medication her took regularly was oral contraceptive pills started a year ago
after her third pregnancy giving birth to twins. She remembered both her mother and
a maternal aunt had their gallbladder removed. The rest of the history and functional
enquiry was not contributory.
Examination revealed a female patient of stated age. She showed no sign of distress;
there was no discoloration of her sclera; her body mass index (BMI) was 25.1; her
vital signs were BP 125/75 mmHg, pulse rate 72/min, respiratory rate 16/min.
Palpation of the abdomen revealed no tenderness and no organomegaly.
1. What are the differential diagnoses?
The causes of epigastric pain are legion and include conditions in many organ
systems: esophageal spasm, gastritis, gastric or duodenal ulcer, gallstone
disease, pancreatitis, mediastinitis, myocardial ischemia, even chest wall pain,
and many others. In the context of this patient, both peptic ulcer and gallstone
disease are the most likely diagnoses. This patient had many risk factors for
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gallstone formation and her pain was not relieved by antacid, which makes the
diagnosis of gallstone disease more probable.
2. What risk factors for gallstone formation did this patient have?
Her risk factors include: age over 40, female gender, multiple pregnancy, oral
contraceptive medication, obesity, maternal history of gallstones. (Review this
subject in “Case 050: Gallstones, gallstones, gallstones” at http://www.medicine-
on-line.com.)
Patient’s progress: The patient’s complete blood count, fasting blood sugar, and
plasma lipid profiles were normal. 13C urea breath test was negative. Ultrasound of
the gallbladder revealed two 0.5 cm stones at the neck of the gallbladder. These
stones were not impinging on the cystic duct. The gallbladder was not enlarged and
its wall was smooth and not thickened. The intra-hepatic ducts and common bile duct
were normal in diameter.
3. What was this patient’s pain attack due to?
The negative 13C urea breath test indicates that she did not have helicobacter
pylori related peptic ulcer disease. She had no constitutional signs of fever or
leukocytosis; her condition was biliary (gallstone) colic. There is some confusion
about the presentation of this condition and some clarification is in order:
Although called “colic”, the pain is more often steady in nature instead of
coming in waves. Onset is abrupt and intensity rises quickly to a crest and
lasts for only a matter of hours.
The pain arises from spasm of the cystic duct. Location of the pain is
primarily in the epigastrium and may radiate to the right shoulder and the
back between the scapulas.
Classic teaching is that the pain is precipitated by fatty meals, but this is
not always the case and pain may come on long after a meal.
4. What is the treatment for biliary colic?
Once a patient with gallstone has an attack of biliary colic, the chance of having a
repeat attack is as high as 70% sometime in the future. It is not possible to tell
which patient will and which patient will not. It is equally impossible to tell when
the next attack is going to be; many patients do remain symptom-free for several
years. After a first biliary colic, many surgeons would recommend gallbladder
removal to prevent a future attack. This is a decision to be made cooperatively
between the patient and his surgeon after full disclosure of pros versus cons and
risks versus benefits of the procedure. Since the 1980’s “laparoscopic
cholecystectomy” has become the standard of practice. The classic technique of
“open cholecystectomy” is reserved for patients deemed not suitable for the
laparoscopic approach (e.g. patients who have had extensive upper abdominal
surgery). The benefits of the laparoscopic approach include less postoperative
pain, shorter hospital stay, and faster return to normal activities and work. The
need to convert from the laparoscopic approach to open surgery due to technical
difficulties is less than 5%. Postoperative bile leak is a potential complication,
which is between 1 and 3%. Common bile duct injury is another potential
complication that may require reconstructive surgery depending on the type of
injury.
For patients who prefer not to have surgery or for those who have high operative
risks due to concurrent illnesses, there is a choice for non-surgical treatment.
They include gallstone dissolution by oral ursodeoxycholic acid (Actigall) or
extracorporeal shock-wave lithotripsy. Success rate for both is low and they are
expensive, time consuming, and do not prevent recurrence of new gallstones.
Further reading
Ruiz O. Cholelithiasis and cholecystitis. In Rakel: Conn’s Current Therapy, 58th

edition. Saunders;2006.
Ahmed A et al. Management of gallstones and their complications. American Family

Physician 2000;61:1673-80.

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http://www.medicine-on-line.

com Biliary colic: 1/4

Case 052: Biliary colic

Author: John Wong MBChB, FRCSEd

1. What are the differential diagnoses?

3. What was this patient’s pain attack due to?

4. What is the treatment for biliary colic?

Ruiz O. Cholelithiasis and cholecystitis. In Rakel: Conn’s Current Therapy, 58th

Ahmed A et al. Management of gallstones and their complications. American Family

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