Approach to biliary colic: Clinical sciences

Biliary colic refers to sudden onset of epigastric or right upper quadrant pain caused by a transient blockage within the biliary tree, most commonly caused by gallstones in the gallbladder, cystic duct, or the common bile duct. Biliary colic is often a diagnosis of exclusion, meaning it comes after you rule out more severe can’t-miss diagnoses.

When assessing a patient with signs and symptoms of biliary colic, you should first perform an ABCDE assessment to determine whether your patient is unstable or stable.

If the patient is unstable, consider cholangitis or another etiology of pain, and start with acute management to stabilize them first. This means that you might need to intubate the patient, obtain IV access, or administer fluids before continuing with your assessment. At this step, you should look for signs of conditions that cause instability, like sepsis.

Alright, now that we’re done with the acute management of unstable patients, let’s talk about stable patients.

Your first step for stable patients with suspected biliary colic is to start supportive care. This means that you need to obtain IV access for fluid resuscitation, initiate bowel rest, and administer pain medication, antispasmodics, and antiemetics if needed.

Once these important steps are done, obtain a focused history and physical examination.

Now, history typically reveals colicky right upper quadrant pain, which is described as a cramp or sharp pain that’s often severe and tends to start and end suddenly in spasms. The pain can radiate to the shoulder or scapula, and is often associated with fatty food intake, or the patient might report associated nausea and vomiting.

On a physical exam, patients with gallbladder inflammation have pain on palpation of the right upper quadrant and a positive Murphy sign. You can elicit Murphy sign by palpating the right upper quadrant while asking the patient to take a deep breath. If the pain suddenly interrupts the inspiration, the Murphy sign is considered positive. Now, if you see these signs and symptoms together, you should consider gallbladder inflammation or infection.

Here are some high-yield facts to keep in mind! While taking the history, be on the lookout for predisposing risk factors for gallbladder and biliary disease. These include biological female sex, obesity, rapid weight loss, a history of gallstones, as well as age over 40.