Biliary Colic

Biliary colic is episodic pain caused by transient obstruction of the cystic duct by a gallstone without established gallbladder inflammation.

Despite the term colic, the pain is usually steady rather than intermittently cramping. Gallbladder contraction against an obstructed cystic duct raises intraluminal pressure until the stone disimpacts.

The distinction from acute cholecystitis is principally duration and inflammation. Biliary colic resolves when obstruction ends. Persistent obstruction produces gallbladder inflammation and acute cholecystitis.

Pain is usually located in the epigastrium or right upper quadrant and may radiate to the right shoulder, scapula or back.

Attacks frequently follow meals but can occur at any time.

Pain builds over minutes, remains relatively constant and usually lasts approximately 30 minutes to several hours.

Nausea and vomiting may accompany severe attacks.

Between episodes the patient is usually well.

Features inconsistent with uncomplicated biliary colic include:

• Persistent pain beyond approximately 6 hours
• Fever
• Marked right upper quadrant guarding
• Systemic toxicity
• Jaundice
• Hypotension

These require investigation for acute cholecystitis, common bile duct obstruction, cholangitis, pancreatitis or another acute abdominal process.

Right upper quadrant ultrasound: confirms gallstones and should show no convincing inflammatory gallbladder changes.

Full blood count and inflammatory markers are usually normal.

Liver tests should be normal in isolated cystic duct obstruction. A significant bilirubin or alkaline phosphatase rise should prompt assessment of the common bile duct.

Check serum lipase when epigastric pain is severe, prolonged or radiates prominently to the back.

Treat the acute episode with analgesia.

A practical first line option is:

Diclofenac 75 mg IM once

or

Diclofenac 50 mg orally up to three times daily as required, if renal function, gastrointestinal bleeding risk and cardiovascular risk permit.

An alternative is:

Ibuprofen 400 mg orally every 8 hours as required.

For severe pain when NSAIDs are contraindicated or inadequate:

Morphine 0.05 to 0.1 mg/kg IV, titrated to clinical response.

Antibiotics are not indicated because uncomplicated biliary colic is not an infection.

Once symptoms resolve, arrange laparoscopic cholecystectomy because recurrent episodes and complications can occur while waiting for surgery.

Repeated attacks should not be managed indefinitely with analgesics alone in an otherwise suitable operative candidate.

If pain does not settle as expected, reconsider the diagnosis rather than repeatedly escalating analgesia.