eMedicine Specialties > Gastroenterology > Biliary

Biliary Colic

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

Introduction

Background

Biliary colic is a symptom of discomfort and is often not accompanied by any clinical signs. It represents one of the causes of epigastric pain. It is the most common presentation of symptomic gallstone disease (cholelithiasis/choledocholithiasis). Because this is a symptom, numerous other disease processes may result in pain that is similar to biliary colic, and, certainly, biliary colic is not the most common cause of epigastric pain. For this reason, other disease processes should be considered during the evaluation of patients being considered to have biliary colic.

Careful history and examination are cornerstones to making an accurate clinical diagnosis, essentially because of the high incidence of gallstones in the population and because most gallstones are asymptomatic. The potential disastrous implications of a misdiagnosis as biliary colic instead of alternative diagnoses that may present with epigastric pain (eg, atypical myocardial ischemia) cannot be overemphasized. Patients also can be particularly unhappy and frustrated when their pain is not resolved following cholecystectomy. The differential diagnosis section lists other important medical conditions one should consider in patients who present with possible biliary colic (see Differentials).

History should elicit the nature, intensity, location, duration, onset, cessation, associated factors, aggravating factors, relieving factors, radiation, and frequency (NILDOCARRF) of the pain (see History). The pain of biliary colic is listed inaccurately as a colic. This term implies a paroxysmal pain that waxes and wanes, when, in actuality, the pain of biliary colic is generally a constant and slowly progressive pain. The pain generally follows a meal and may wake up a person several hours later. In fact, pain immediately with a meal is not characteristic of biliary colic.

It is important while taking the history that one evaluates the risk factors for stone formation, addresses and excludes other potential causes for the pain, and concurrently evaluates medical comorbidities that may influence management (eg, cardiovascular disease).

This visceral pain is believed to result from impaction of a gallstone in the cystic duct and/or ampulla of Vater. The resulting impaction causes distension of the gallbladder and/or biliary tract, and this distension activates visceral afferent sensory neurons. The resultant pain is commonly localized poorly and generally refers midline to the representative dermatomes T8/9 (mid epigastrium, right upper quadrant), although it may radiate to the right upper quadrant. Localized pain or persistent pain generally represents a complication of cholelithiasis or choledocholithiasis (eg, cholecystitis, cholangitis, pancreatitis). 

Biliary colic is the presenting symptom in 80% of patients with gallstone disease who seek medical care; however, only 10-20% of all individuals with gallstones experience severe gallstone pain. The risk of developing biliary pain or stone-related complications in asymptomatic patients is low, at 1-2% per year. For this reason, clinical practice favors treatment of only symptomatic disease, with the exception of a few unique circumstances. Two thirds of patients presenting with their first attack of biliary colic have recurrent pain within 2 years.

Nonpain symptoms that may be associated with biliary colic are inconsistently relieved with cholecystectomy (approximately 44%) and are more likely relieved in the presence of gallstones than in acalculous disease.

Fatty food intolerance (fatty dyspepsia) is not a symptom of biliary colic.

Pathophysiology

A gallstone produces visceral pain by obstructing the cystic duct or ampulla of Vater, resulting in distention of the gallbladder or biliary tree. Pain is relieved when the gallstone migrates back into the gallbladder, passes through the ampulla, or falls back into the common bile duct (CBD). The pain of biliary colic may accompany sphincter of Oddi spasm.

See related CME at New Guidelines Address Management of Common Bile Duct Stones.

Frequency

United States

Asymptomatic individuals with gallstones develop pain at an annual rate of 1-4%, with approximately 10% of individuals developing symptoms in 10 years and 20% developing symptoms in 20 years.

International

Limited international data appear to support a similar incidence of biliary colic in all populations with gallstones. The incidence of gallstones is greater in some races and cultures than in others.

Mortality/Morbidity

By definition, uncomplicated gallstone disease is not associated with signs or symptoms of systemic disease, such as fever, jaundice, or leukocytosis. Patients with uncomplicated gallstone disease experience self-limited pain. Presentation is associated with only limited morbidity and never mortality, despite some patients' perception of the severity of pain and its significance. The frequency of progression to acute cholecystitis is 10-30%. Ibuprofen use may decrease the likelihood of progression.

Race

In the United States, the prevalence of gallstone disease is highest among Hispanic Americans and Native Americans, especially the Pima Indians of Arizona, with 75% of women developing cholesterol gallstones by early adulthood.

Sex

Biliary colic is more common in women than in men, primarily related to the 2- to 3-fold increased incidence of cholelithiasis in women.

Age

The incidence of biliary colic depends on the incidence of gallstones. For this reason, the condition is rare in patients younger than 20 years and increases with age, occurring in approximately 2-4% of men older than 60 years and approximately 3-8% of age-matched women.

Clinical

History

Note that, in general, there is no clear association between the presence of gallstones and upper abdominal pain.¹

• Abdominal pain
  • Biliary colic usually starts abruptly and reaches maximum intensity within 60 minutes in two thirds of patients.
  • The pain generally continues without fluctuation and resolves gradually over 2-6 hours. Pain lasting longer than 6 hours should raise the suspicion for acute cholecystitis.
• NILDOCARRF
  • Nature: Many persons with this condition have difficulty describing the nature of the pain. It is a vague aching/cramping discomfort and generally is not sharp. The pain is constant rather than colicky; however, some interindividual variability exists.
  • Intensity: Among individuals, intensity is quite variable; however, the pain may be severe. Prolonged severe pain should raise concern that another etiology may be present.
  • Location: The epigastrium is the most common site, followed by the right upper quadrant; however, it may be located in many different sites within the abdomen. The pain tends to recur at the same sites. Infrequently (7%), pain may be represented in a retrosternal location.
  • Duration: The pain lasts from 30 minutes to 6 hours.
  • Onset: Progressive in onset, it reaches peak intensity within 30-60 minutes.
  • Cessation: Gradual persistent pain increases the likelihood of another etiology for the pain, including other complications of gallstones.
  • Associated factors: This condition may be associated with nausea, vomiting, or diaphoresis. Patients often cannot get comfortable. Patients generally do not have a fever.
  • Aggravating factors: Pain often follows a few hours after meals and may occur at night and wake the patient from sleep. Pain traditionally does not occur with meals or very soon after. Morphine has been noted to increase the pain in some people with biliary colic secondary to sphincter of Oddi dysfunction (SOD).
  • Relieving factors: Narcotic analgesia, nonsteroidal anti-inflammatory drugs (NSAIDs), and nitrates help relieve the pain.
  • Radiation: Pain may radiate to the right upper quadrant and to the back, following the subcostal margin. Other less common sites include retrosternal areas and the left upper quadrant. Isolated left arm (cardiac) and sharp right shoulder tip pain (cholangitis) should prompt consideration of alternative diagnoses.
  • Frequency: If the patient has had a previous attack, the likelihood of recurrence is higher. Fatty meals inconsistently elicit the pain, and nocturnal occurrence of pain is not infrequent. Repeat bouts in the same day may herald other complications.
• Uncomplicated biliary colic leaves no persisting symptoms following the acute attack.
• Finally, in relation to the patient with acalculous disease with a question of biliary pain, the ROME II diagnostic criteria were published to help evaluate the patient considered to have gallbladder dysmotility. These criteria are listed below. Note that all criteria are pain related.
  • Episodes of severe steady pain located in the epigastrium and right upper quadrant
  • All of the following:
    • Symptom episodes last 30 minutes or more, with pain-free intervals.
    • Symptoms have occurred on 1 or more occasions in the previous 12 months.
    • The pain is steady and interrupts daily activities or requires consultation with a physician.
    • There is no evidence of structural abnormalities to explain the symptoms.
    • There is abnormal gallbladder functioning with regard to emptying.

Physical

• Initial inspection often reveals an individual who is diaphoretic, pale, rolling about, and unable to get comfortable. Vomiting may accompany the pain.
• Examination may reveal some of the physical features associated with gallstone formation (eg, overweight, middle-aged, female).
• Occasionally, features of other conditions associated with an increased incidence of gallstones may be observed. This may extend to observing an individual with jaundice with stigmata of chronic liver disease. More often than not, physical findings are more important for excluding other causes for the pain.
• Patients with uncomplicated biliary colic do not have fever, chills, hypotension, or other signs of a significant systemic process.
• Sinus tachycardia is common during pain.
• Much interindividual variability exists when the pain is described; generally, it is at the milder end of the spectrum, although the pain may be excruciating for some individuals.
• Rebound, guarding, absent bowel sounds, or a palpable mass support an alternate diagnosis.

Causes

The risk factors for cholelithiasis have been outlined in Cholelithiasis. 

A postulate explaining the greater nocturnal occurrence of biliary colic pain concerns the biliary anatomy. The horizontal lie of the gallbladder upon recumbency (sleeping) is believed to predispose patients to stone migration and subsequent impaction.

• Biliary dyskinesia and SOD present with a pain that often is consistent with biliary colic. These individuals often have undergone cholecystectomy without resolution of symptoms.
• Recurrent pain occurs in as many as 20% of people who have undergone cholecystectomy and is most common in those who have undergone cholecystectomy for acalculous disease or for atypical symptoms.
• Before allocating someone to the category of biliary dyskinesia/SOD, considering other causes of the symptoms described, particularly those outside the biliary system, is important. Investigations should focus on excluding retained stones in the biliary system. Treatment of SOD should take place at select institutions with extensive experience in this area. The investigation and treatment of this condition are beyond the scope of this article; however, a brief summary follows:
  • SOD is uncommon and accounts for 10% of people with postcholecystectomy abdominal pain in one series. It is a difficult diagnosis to establish and involves a combination of careful history, possibly some supportive laboratory tests, and cholangiography to exclude choledocholithiasis. Often, sphincter of Oddi manometry is performed.
  • Those most likely to respond to treatment by endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy are those with a history of classic biliary pain, abnormal liver enzymes in association with the pain, and delayed drainage post-ERCP.
  • Relief of pain after stenting the sphincter also is predictive of response to sphincterotomy.
  • Some trials have shown support for the use of nifedipine and nitrates in selected populations.

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