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

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.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Chronic Cholecystitis

Chronic cholecystitis is chronic inflammatory and fibrotic remodelling of the gallbladder, usually caused by repeated episodes of gallstone related cystic duct obstruction.

The gallbladder becomes thickened, fibrotic and poorly contractile. Advanced disease may produce a small contracted gallbladder densely adherent to surrounding structures.

Chronic cholecystitis is usually the pathological substrate behind recurrent symptomatic gallstone disease rather than a distinct acute inflammatory syndrome.

The major surgical importance is that longstanding fibrosis can make identification of biliary anatomy difficult and increase bile duct injury risk.

Patients commonly report recurrent episodes of right upper quadrant or epigastric pain compatible with biliary colic.

Symptoms may be provoked by meals and associated with nausea.

Unlike acute cholecystitis, fever and persistent inflammatory signs are absent between episodes.

Chronic vague dyspepsia alone is poorly specific for gallbladder disease and should not automatically be attributed to gallstones.

Right upper quadrant ultrasound: usually demonstrates gallstones with a fibrotic or contracted gallbladder; the decisive finding is gallstone disease corresponding to the patient\'s recurrent biliary symptoms.

Laboratory tests are often normal between attacks.

Abnormal bilirubin or cholestatic liver enzymes should prompt evaluation for common bile duct stones rather than being attributed to chronic cholecystitis.

A markedly irregular or mass like gallbladder wall requires evaluation for gallbladder malignancy before routine elective surgery.

Symptomatic chronic cholecystitis is treated with elective laparoscopic cholecystectomy.

Antibiotics are unnecessary in the absence of acute infection.

The operation can be technically difficult when the gallbladder is shrunken and densely fibrotic.

Dissection should be directed toward a safe critical view rather than toward completing a conventional cholecystectomy at any cost.

If the cystic duct and artery cannot be confidently defined:

Stop dissection within the dangerous hepatocystic triangle
Use intraoperative imaging when it will clarify biliary anatomy
Perform subtotal cholecystectomy when necessary
Convert to open surgery when exposure or control will genuinely improve

A subtotal cholecystectomy is a deliberate bailout operation, not a failure, when complete removal would expose the common bile duct or hepatic ducts to unacceptable risk.

If the gallbladder is unexpectedly indurated, mass like or inseparable from adjacent liver, avoid opening or fragmenting a possible malignancy. Obtain appropriate oncological assessment and modify the operation according to the findings.

After uncomplicated elective laparoscopic cholecystectomy, routine postoperative antibiotics are not indicated.

Biliary Colic

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management