eMedicine Specialties > Gastroenterology > Biliary

Biliary Colic: Follow-up

Author: Richard K Gilroy, MBBS, FRACP, Associate Professor, Medical Director of Liver Transplantation and Hepatology, Department of Internal Medicine, Kansas University Medical Center
Coauthor(s): Sandeep Mukherjee, MB, BCh, MPH, FRCPC, Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center; Jean Frederick Botha, MBBCh, FCS(SA), Assistant Professor of Surgery, Transplant Surgeon, Department of Surgery, University of Nebraska Medical Center
Contributor Information and Disclosures

Updated: Jul 29, 2008

Follow-up

Further Inpatient Care

• In the setting of continued pain for longer than 6 hours or signs of clinical deterioration, surgical assessment should be undertaken.

Further Outpatient Care

• Patients with biliary colic should be referred for elective cholecystectomy, particularly if symptoms are recurrent.
  • Even high-risk surgical candidates should be considered for laparoscopic cholecystectomy. Good results can be achieved in these patients, and data appear to support this over ERCP. Patients who have had an ERCP remain at risk for biliary complications of gallstone disease. Good data now support laparoscopic cholecystectomy with laparoscopic CBD exploration when undertaken by experienced people rather than ERCP prior to cholecystectomy.
  • In the rare instance in which a patient has had CBD clearance with ERCP and has no residual stones on imaging study, these authors favor cholecystectomy. No randomized data are available to support this; however, "once a stone former, always a stone former … until cholecystectomy."

Inpatient & Outpatient Medications

• No medications should be required after the attack has resolved, and prophylactic medications or prescriptions for outpatient analgesia have no role in this condition.

Deterrence/Prevention

• Cholecystectomy generally cures the pain of biliary colic and is the treatment of choice for this condition. Avoidance of fatty meals does not reduce symptoms of biliary colic, nor does it result in less frequent attacks.

Complications

• Biliary colic lasting longer than 6 hours, fever, and right upper quadrant tenderness may indicate acute cholecystitis; the addition of jaundice to the above symptoms and signs implies cholangitis.
• After the initial presentation, 30% of patients have no further attacks and the approximate frequency of recurrent symptoms after an initial attack is 30% in the 2 years following. Serious complications following an initial attack of biliary colic are uncommon, with a frequency of approximately 1% per year. One study favors routine cholecystectomy for those with symptoms consistent with biliary colic. This is based on reduced overall cost, decreased number of hospitalizations, reduced emergency department visits, and, importantly, diminished likelihood of conversion from a laparoscopic to open procedure and the complications from this surgery.

Prognosis

• Recurrent biliary colic occurs in 50-75% of patients after the initial episode. Most patients who develop complications, such as cholecystitis, experience biliary colic prior to the complications. A cost analysis appears to support referral of those with symptoms of biliary colic for cholecystectomy. Of greatest importance is the fact that biliary colic is the most sensitive and specific symptom of symptomatic cholelithiasis, and one should be aware that other symptoms (eg, bloating) have low specificity for symptomatic gallstone disease.
• Cholecystectomy cures symptoms of biliary colic in approximately 80-85% of patients with gallstones on ultrasound findings. Nonpain symptoms related to cholelithiasis are relieved inconsistently (approximately 40%) by cholecystectomy.
• Postcholecystectomy syndrome encompasses an array of clinical symptoms that persist following cholecystectomy. They may be of biliary or nonbiliary origin. More often, these are symptoms like bloating, excessive flatulence, and fatty-food intolerance. In any event, if the primary indications for cholecystectomy are these atypical symptoms, it is imperative that during informed consent a patient is made aware that these are not improved consistently following cholecystectomy. Every good operation has its indications and limitations. To discuss and document these for every individual patient is important.
  • Disorders that warrant exclusion, in the event that pain persists following cholecystectomy, include those of both biliary and nonbiliary origins. Retained stones in the CBD (ie, choledocholithiasis) should have been excluded with an operative cholangiogram, and this is a good place to start with the workup of persisting symptoms. Clinical data that would support choledocholithiasis include any feature of cholangitis, clinical stigmata of obstruction, and laboratory tests (ie, increased bilirubin or liver enzymes following attacks).
  • Nonbiliary causes include gastrointestinal disorders (eg, reflux esophagitis, peptic ulcer disease), nongastrointestinal disorders (eg, atypical angina), and, importantly, functional disorders, such as irritable bowel syndrome (IBS). Another word of caution is that 2 common conditions may coexist (ie, gallstones and IBS). To reiterate, a careful history is the cornerstone of establishing a provisional diagnosis of biliary colic in an individual (commonly a middle-aged female) who may present with IBS and gallstones on US findings.
• The difficult patient is one for whom data on the most appropriate therapy is not available. This is the high-risk surgical patient with biliary colic. A good study that endeavors to address this is that by Targarona et al, which favors laparoscopic cholecystectomy over ERCP with sphincterotomy for choledocholithiasis.²
• Carr-Locke's group showed that, even with sphincterotomy, the risk of recurrent biliary tract related symptoms or complications was significant (approximately 20%).³
• The ongoing challenges in biliary tract disease are outside the scope of this article; however, a good review article on this subject is that by Stiegmann.⁴

Patient Education

• Information relating to the options available in the treatment of biliary colic should be provided.
• Advise patients that, over the next 2 years, they have a 50% chance of a repeat attack of biliary colic and that they also have a chance that subsequent attacks may be associated with complications, such as cholangitis; however, this is uncommon.
• The limitations of surgery probably should be outlined; in particular, recurrent pain consistent with biliary colic may occur in 10-20% of people after surgery and that nonpain symptoms are relieved inconsistently.
• For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Center and Cholesterol Center. Also, see eMedicine's patient education articles Gallstones and Abdominal Pain in Adults.

Miscellaneous

Medicolegal Pitfalls

• Care should be taken to establish the correct diagnosis. Do not advise a patient that because gallstones are present on imaging studies and that they have pain consistent with biliary colic that cholecystectomy will cure the problem.
• Postcholecystectomy syndrome was discussed earlier (see Prognosis), and patients must be made aware that the procedure of cholecystectomy works well for classic biliary colic symptoms; however, pain may recur after the procedure. Recurrence of classic symptoms following cholecystectomy may signify choledocholithiasis. The persistence of atypical symptoms often signifies that the working diagnosis before cholecystectomy was incorrect. The operation is not a cure-all, and some individuals develop new symptoms following the procedure. Providing realistic expectations and clear communication both before and after the procedure are key to avoiding potential litigation.

Special Concerns

• People with cirrhosis and pregnant individuals with biliary colic should be considered on a case-by-case basis. Most would suggest that those with an initial attack of uncomplicated biliary colic should be observed.
  • In patients with symptomatic gallstone disease and Child-Turcotte-Pugh class A/B cirrhosis, elective laparoscopic cholecystectomy can be performed safely, and some authors believe that this procedure should be considered for individuals with symptomatic gallstone disease to prevent biliary tract complications.
  • Symptomatic gallstone disease in pregnancy can be treated safely with laparoscopic cholecystectomy in the second trimester and should primarily target those with severe symptoms. However, biliary colic is uncommon during pregnancy.
• A population not covered in this article but deserving of mention is the pediatric population with biliary dyskinesia who can present with symptoms of biliary colic.  Gallbladder ejection fractions appear to assist the physician in predicting those patients who may respond to cholecystectomy, with a value of less than 15% being predictive.

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