Biliary Colic - A Complete, Easy-to-Understand Guide

What is Biliary Colic?

Despite the word "colic," the pain is usually steady, not wave-like.

The Gallbladder and Its Location

LIVER
 └── Gallbladder (sits underneath)
       └── Cystic duct ──→ Common bile duct ──→ Small intestine

What Are Gallstones?

Two Main Types

Real Gallstones - What They Look Like

Risk Factors - The "5 F's" and More

How Biliary Colic Happens - Step by Step

1. You eat a fatty meal → the gallbladder gets a signal (cholecystokinin) to contract
2. A stone lodges in the cystic duct as bile tries to flow out
3. Pressure builds inside the gallbladder → visceral pain signals fire (T8/T9 dermatomes)
4. You feel severe right upper quadrant or epigastric pain, sometimes radiating to the right shoulder blade
5. The stone shifts back into the gallbladder or passes through → pain stops within minutes to hours
6. Next attack: could be days, weeks, or even years later

Symptoms

Physical Examination

• Mild right upper quadrant tenderness on pressing
• No rebound tenderness, no rigidity (no peritoneal signs)
• Murphy's sign is NEGATIVE in biliary colic (positive Murphy's sign = acute cholecystitis)
• Patient may be distressed during an attack but looks well between attacks

How Is It Diagnosed?

Ultrasound - The Gold Standard

• Echogenic (bright) stones with "acoustic shadowing" behind them
• Possibly a thickened gallbladder wall if there is associated inflammation

CT Scan

Blood Tests

• Elevated WBC → cholecystitis
• Elevated bilirubin/ALP → choledocholithiasis
• Elevated lipase/amylase → gallstone pancreatitis

Biliary Colic vs. Acute Cholecystitis - Key Differences

Potential Complications if Left Untreated

Gallstones (asymptomatic)
        ↓ (minority progress)
Biliary Colic (temporary blockage)
        ↓ (if stone stays stuck)
Acute Cholecystitis (infection + inflammation)
        ↓ (can lead to)
  ┌─────────────────────────────────┐
  │ Empyema (pus in gallbladder)    │
  │ Perforation                     │
  │ Gangrene                        │
  │ Cholangitis (bile duct infect.) │
  │ Gallstone Pancreatitis          │
  │ Gallstone Ileus (bowel blockage)│
  └─────────────────────────────────┘

Treatment

For Biliary Colic (Emergency Department)

1. NSAIDs (first line) - e.g., ketorolac IV/IM. Works as well as opioids and may prevent progression to cholecystitis.
2. Opioids - for severe pain when NSAIDs aren't enough. All opioids cause some sphincter of Oddi spasm, but no specific opioid is superior.
3. Antiemetics - for nausea and vomiting.
4. Anticholinergics (atropine, glycopyrrolate) - do NOT help; not recommended.
5. Discharge home once pain is controlled, with outpatient surgical referral.

Definitive Treatment

• Less post-operative pain
• Shorter hospital stay
• Faster return to normal activity

Asymptomatic Gallstones

• Sickle cell disease
• Pre-organ transplant patients
• Ethnic groups with high gallbladder cancer risk (e.g., certain Native American populations)

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