Approach to biliary colic: Clinical sciences

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Introduction0:00–0:32

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.

Unstable branch0:32–1:11

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.

Stable branch1:11–3:43

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.The next step is to assess for inflammation.
This may indicate that biliary colic has progressed to cholecystitis or cholangitis, so evaluation of these patients includes ordering labs like CBC, alkaline phosphatase or ALP, LFTs including fractionated bilirubin, amylase and lipase.
Additionally, imaging like ultrasound should be done to look for the underlying cause. Now, if labs show leukocytosis; elevated ALP and direct bilirubin, as well as possibly elevated amylase and lipase, there is definitely an inflammation.

Cholecystitis and cholangitis3:43–5:15

This means that your patient may have cholecystitis or acute cholangitis, which you may distinguish based on ultrasound findings.
On the one hand, ultrasound might reveal gallstones in the gallbladder, as well as signs of gallbladder inflammation, such as wall thickening greater than 3 millimeters, or pericholecystic fluid.
These patients can also have a sonographic Murphy sign. This means that the patient feels pain when the ultrasonographer pushes in the right upper quadrant.
So, if you see these ultrasound findings, the patient has cholecystitis. On the other hand, ultrasound might show gallstones in the common bile duct, biliary dilation, and thickening of the bile duct walls.
Sometimes, you’ll see debris within the gallbladder, which indicates biliary sludge. Now, if the patient has these findings as well as jaundice, fever, or signs of sepsis, they have acute cholangitis, also known as ascending cholangitis.
These patients require urgent intervention so their condition does not worsen. Okay, now that inflammatory conditions have been covered, let’s go back to labs and ultrasound.

Biliary colic5:15–6:09

Now, remember that biliary colic is often a diagnosis of exclusion. At this point, you have ruled out more acute pathology, but the patient still has signs and symptoms suggestive of a biliary issue.
So, by exclusion, you should consider non-inflammatory gallbladder disease. Labs would be normal, or possibly reveal elevated alkaline phosphatase, but, importantly, they do not show evidence of inflammation or infection.
Likewise, ultrasound can still reveal gallstones in the gallbladder or the common bile duct, but there will be no signs of gallbladder inflammation.
If you see these findings, you can diagnose the patient with biliary colic. After you’ve ruled out these can’t-miss diagnoses involving the biliary system, you should consider alternative diagnoses that may cause right upper quadrant abdominal pain.

Alternative Diagnoses6:09–6:35

These include pancreatitis, pancreatic pseudocyst, hepatitis, liver failure, peptic ulcer disease, bowel obstruction, or vascular causes like mesenteric ischemia.Alright, as a quick recap… Biliary colic refers to sudden onset of epigastric or right upper quadrant pain caused by a transient blockage within the biliary tree.

Review6:35–7:58

Biliary colic is often a diagnosis of exclusion, meaning it comes after you rule out more severe can’t-miss diagnoses. Unstable patients need to be stabilized, which might require intubation, IV access, and fluid resuscitation.
Once stable, start the patient on supportive care, including IV fluids, bowel rest, possible pain management, antispasmodics, and antiemetics.
Then, obtain a complete history and physical exam. Now, if the patient has signs and symptoms of inflammation and infection, the most probable diagnoses are cholecystitis or cholangitis.
However, if the patient has no signs of infection, they probably have biliary colic caused by gallstones. Finally, once you rule out these can’t-miss diagnoses involving the biliary system, you can consider alternative diagnoses like pancreatitis, pancreatic pseudocyst, hepatitis, liver failure, peptic ulcer disease,