eMedicine Specialties > Gastroenterology > Biliary
Biliary Colic: Differential Diagnoses & Workup
Updated: Jul 29, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
Biliary dyskinesia
Sphincter of Oddi dysfunction
Spinal nerve root compression
Nonulcer dyspepsia
Acute hepatitis
Workup
Laboratory Studies
- CBC count results are normal in uncomplicated biliary colic; an abnormality suggests complicated biliary disease (eg, cholecystitis).
- Aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, bilirubin, and amylase assay results are normal in uncomplicated biliary colic; an abnormality suggests a complication (eg, cholecystitis, cholangitis, pancreatitis).
- If clinical suspicion warrants more extensive investigation into alternate diagnoses, consider creatine kinase and cardiac enzymes evaluation or other investigations accordingly. Minor increases in alkaline phosphatase accompanied by rises in bilirubin may be seen with choledocholithiasis. Increases in AST and ALT accompanied by right upper quadrant pain often herald the development of cholangitis.
Imaging Studies
- Abdominal ultrasound (US) is the diagnostic method of choice to confirm gallstones. US is sensitive (95%), and its specificity is guided by pretest probability.
- The picture of a classic history for biliary colic and gallstones within the gallbladder with some wall edema increases specificity. An atypical history with a single large stone makes this specificity lower, with overall estimates of specificity approximately 60%.
- The test is safe and relatively inexpensive. Negative US findings exclude biliary colic in most instances. Visualizing cystic duct obstruction, the most common cause of biliary colic, is uncommon. Biliary tract dilation also is not observed often.
- Oral cholecystography (55-85%), although at times sensitive (ie, when the gallbladder is able to be filled with contrast, sensitivity is 90%) for the evaluation of gallstones, has been replaced by US.
- It may have advantages over US for assessing cystic duct patency and gallbladder function, but this indication is infrequent and is reserved for those with symptomatic gallstones who are elderly and not operative candidates.
- Dissolution therapy may be contemplated but rarely is it indicated.
- Hepatobiliary (hepatoiminodiacetic acid) scintigraphy may have a role in evaluating acute cholecystitis. It has a role when classic symptoms of biliary colic occur and imaging studies fail to demonstrate stones (see Media file 2).
- Generally, either cholecystokinin (CCK) or morphine is added to improve the sensitivity of the test, although much controversy surrounds the sensitivity and specificity of the addition of morphine to the procedure.
- Ejection fractions of less than 50% have been found with those more likely to respond to cholecystectomy; however, some authorities suggest values of less than 35%. Lower ejection fractions provide increased specificity at the expense of sensitivity.
- In the context of typical symptoms of biliary colic and an ejection fraction of 20%, these authors usually would recommend cholecystectomy.
- ERCP has a role in patients with persisting symptoms consistent with biliary colic that have failed to resolve with cholecystectomy. The aim is to primarily exclude choledocholithiasis.
- When used with biliary manometry, ERCP is useful for predicting which patients are more likely to respond to sphincterotomy, in particular those classified as type II SOD.
- ERCP has a therapeutic role in type I and type II SOD. It is the means by which a sphincterotomy may be performed to treat this condition.
- Some authors use this procedure to aspirate bile, looking for crystals. Using the results of this procedure for predicting those who will respond to cholecystectomy has not been validated at this point.
- Abdominal x-ray has a very low sensitivity and specificity in the diagnosis of biliary colic. The role is to exclude other pathology (eg, bowel obstruction, perforation).
- Magnetic resonance cholangiopancreatography has the same role as ERCP in biliary disease. It offers no advantage over US but may have a role when one is looking for a retained common duct stone.
- Patients who have had gallstones removed at ERCP (ie, those who have had a sphincterotomy), who have negative findings for cholelithiasis on US, and who are candidates for surgery should be offered cholecystectomy.
- High-risk candidates referred for elective cholecystectomy should be considered on a case-by-case basis.
- Patients with cholelithiasis and choledocholithiasis who are operative candidates should be offered laparoscopic cholecystectomy and CBD exploration, acknowledging a 5% chance of conversion to an open procedure.
Procedures
- Surgery is recommended for symptomatic gallstone disease, and all symptomatic individuals should be considered for laparoscopic cholecystectomy when appropriate.
- Patients at higher-than-normal operative risk must be considered individually. Cost and risk-benefit analysis does not support prophylactic cholecystectomy in asymptomatic individuals; however, it does support surgical intervention in symptomatic individuals. This is discussed in Cholelithiasis.
Histologic Findings
Cholecystectomy specimens often show changes consistent with chronic cholecystitis (see Cholecystitis). Gallstones are found in most surgical specimens.
More on Biliary Colic |
| Overview: Biliary Colic |
 Differential Diagnoses & Workup: Biliary Colic |
| Treatment & Medication: Biliary Colic |
| Follow-up: Biliary Colic |
| Multimedia: Biliary Colic |
| References |
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References
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Further Reading
Keywords
biliary colic, gallstones, cholelithiasis, choledocholithiasis, biliary tract disease, gallstone disease, cholecystitis, gallstone attack, bilious pain, epigastric pain, cholecystectomy, cystic duct obstruction, flatulent dyspepsia, sphincter of Oddi spasm, sphincter of Oddi dysfunction
