eMedicine Specialties > Gastroenterology > Biliary
Biliary Colic: Treatment & Medication
Updated: Jul 29, 2008
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Treatment
Medical Care
Supportive measures are indicated for patients with uncomplicated biliary colic, with symptoms usually resolving within 2-3 hours. Continuous or recurrent symptoms despite analgesia likely herald a complication of gallstone disease, most commonly acute cholecystitis.
- Pain
- Most authors favor narcotic analgesics over other agents for the immediate relief of pain. Meperidine (pethidine) at 1-1.5 mg/kg intramuscular injection (not to exceed 100 mg) every 3 hours is preferred. In view of the theoretical association with increased biliary motility and spasm, morphine generally is avoided.
- Several controlled trials of diclofenac, tenoxicam, and ketorolac seem to have demonstrated therapeutic benefits in both pain relief and decreased likelihood of progression to acute cholecystitis. An increase in adverse effects in patients who are dehydrated or elderly should be considered. In the setting of nausea and vomiting, a parenteral route is favored.
- Antispasmodics (eg, papaverine, atropine) and nitrates have a very limited, if any, role in the treatment of biliary colic.
- Nausea: Use metoclopramide or prochlorperazine intravenously.
Surgical Care
No acute surgical intervention is warranted because uncomplicated biliary colic resolves with conservative treatment.
- Several studies have reviewed the treatment of symptoms believed to be related to gallstones.
- Patients who undergo elective cholecystectomy for biliary colic have shorter lengths of stay in the hospital and less complicated operative courses than those presenting with complications of gallstone disease. Relief of symptoms occurs in approximately 85% of individuals. The procedures performed were, on the average, shorter and with shorter periods of convalescence. Many authors favor elective surgery for patients with biliary colic.
- Patients with atypical (ie, nonpain) symptoms show inconsistent relief of these symptoms (eg, fatty food intolerance, flatulent dyspepsia). Laparoscopic therapy is favored.
- In patients with symptoms of biliary colic without gallstones, the treatment options become more difficult. A combination of a positive biliary scintigraphy with CCK (ejection fraction <50%) and classic symptoms appears to respond the best to cholecystectomy. In general, patients with symptoms typical of biliary colic, with normal US findings, positive scintigraphy findings, and no evidence of acid-peptic disease, have the greatest benefit from laparoscopic cholecystectomy. Patients with symptoms that persist after cholecystectomy warrant evaluation in specialized facilities that focus on biliary motility disorders.
- Nonsurgical treatment is selected for high-risk surgical candidates.
Consultations
Early surgical consultation is appropriate if symptoms do not resolve in the expected time frame. Persistent symptoms suggest the possibility of acute cholecystitis. In those in whom a diagnosis is established and symptoms resolve, elective consultation is appropriate.
Diet
During the acute attack, patients typically are anorectic. After resolution of the attack, some authors favor avoidance of high-fat meals. Controlled data are lacking to support this approach, and a liberal healthy diet is not unreasonable. A diet to prepare an individual for surgery is advised (eg, weight reduction in patients who are obese).
Activity
Bed rest usually is recommended until the pain resolves; patients may resume full activity thereafter.
Medication
NSAIDs and/or opiate agonists are used to provide pain relief. Nausea is treated with antiemetics and intravenous fluids for consequent dehydration.
Analgesic agents
Pain control is essential to quality patient care. NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. They are used for mild to moderate pain. Their mechanism of action is unknown, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist (eg, inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, various cell membrane functions). Opioid analgesics act at the CNS mu receptors. They are inexpensive and have proven effective.
Meperidine (Demerol)
Analgesic with multiple actions similar to those of morphine; may produce less constipation, smooth-muscle spasm, and depression of cough reflex than equal analgesic doses of morphine.
Adult
50-150 mg PO/IV/IM/SC q3-4h prn
Pediatric
Not established; problem rare <20 y
Increased respiratory and CNS depression with coadministration of cimetidine; hydantoins may decrease effects; protease inhibitors (eg, ritonavir) may increase normeperidine levels, enhancing risk of CNS toxicity
Documented hypersensitivity; within 2 wk of MAOIs; upper airway obstruction or significant respiratory depression; intracranial lesions; multiple doses in patients with renal failure; predisposition to seizures; during labor when delivery of premature infant is anticipated
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Category D with prolonged use or high doses at term; caution in patients with head injuries, may increase respiratory depression and CSF pressure; caution postoperatively and in patients with history of pulmonary disease (suppresses cough reflex); increased doses due to tolerance may aggravate or cause seizures (even without prior history); caution in patients with renal dysfunction (decrease dose), do not use in patients with severe renal dysfunction, normeperidine metabolite accumulation may induce CNS toxicity
Hydromorphone (Dilaudid)
Potent semisynthetic opiate agonist similar in structure to morphine. Approximately 7- to 8-times as potent as morphine on mg-to-mg basis, with shorter or similar duration of action (ie, 4-5 h).
Adult
1-2 mg IV/IM/SC q4h; adjust dose according to pain scale assessment
Pediatric
Not established; problem rare <20 y
Additive sedation and respiratory depression with other drugs causing CNS depression; drugs inducing CYP450 metabolism (eg, rifampin, phenytoin, carbamazepine) may decrease hydromorphone effect
Documented hypersensitivity; do not use for obstetrical analgesia, increased intracranial pressure, or respiratory depression; ulcerative colitis; Crohn disease; relative contraindications include abdominal cramping and distention
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Category D with prolonged use or high doses at term; caution in patients with head injuries, may increase respiratory depression and CSF pressure; caution postoperatively and in patients with history of pulmonary disease (suppresses cough reflex); caution in patients with impaired hepatic function (decrease dose), hypothyroidism, Crohn disease, ulcerative colitis, Addison disease, or prostatic hypertrophy
Ibuprofen (Motrin, Advil, Ibuprin)
Indicated for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
Mild to moderate pain: 400 mg PO q4-6h prn; not to exceed 3.2 g/d; IM dosing for those with concurrent nausea
Pediatric
Not established; problem rare <20 y
Coadministration with aspirin increases risk of serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase methotrexate toxicity; phenytoin levels may increase when administered concurrently
Documented hypersensitivity; active peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Category D in third trimester of pregnancy; caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in patients with coagulation abnormalities or during anticoagulant therapy
Ketorolac (Toradol)
Inhibits prostaglandin synthesis by decreasing activity of cyclooxygenase, which results in decreased formation of prostaglandin precursors.
Adult
30-60 mg IM initially, followed by 15-30 mg q6h; alternatively 15-30 mg IV initially, followed by 15-30 mg IV prn; not to exceed 120 mg/d (60 mg/d in renal failure, >65 y, or <50 kg); not to exceed 5 d of treatment
Pediatric
Not established; problem rare <20 y
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; do not administer into CNS
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy; may cause acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; leukopenia (rare) usually returns to normal during ongoing therapy; discontinue therapy if persistent leukopenia, granulocytopenia, or thrombocytopenia occur; decrease dose in renal failure, >65 y, or <50 kg
Antiemetic agents
The CNS vomiting center (VC) may be stimulated directly by GI irritation. Increased activity of central neurotransmitters, dopamine in the chemoreceptor trigger zone, or acetylcholine in the VC appears to be a major mediator for inducing vomiting. Antidopaminergic agents (eg, metoclopramide, phenothiazines) are effective for nausea due to GI irritation.
Metoclopramide (Reglan)
Dopamine antagonist that stimulates acetylcholine release in the myenteric plexus. Acts centrally on chemoreceptor triggers in the floor of the fourth ventricle, which provides important antiemetic activity.
Adult
10 mg IV q6h prn
Pediatric
Not established; problem rare <20 y
Opioid analgesics may increase toxicity in CNS; may cause additive effect with other drugs that cause extrapyramidal reactions; hypertension observed with coadministration of MAOIs, tricyclic antidepressants, or sympathomimetics; may increase serum levels of cyclosporine, sirolimus, or tacrolimus; may decrease digoxin serum levels
Documented hypersensitivity; pheochromocytoma; GI hemorrhage, obstruction, or perforation; history of seizure disorders
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in breastfeeding women, patients with depression, hypertension, Parkinson disease, and conditions aggravated by anticholinergic or antidopaminergic effects; may cause tardive dyskinesia
Prochlorperazine (Compazine)
May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system.
Adult
5-10 mg PO/IM tid/qid; not to exceed 40 mg/d; alternatively, 2.5-10 mg IV q3-4h prn; not to exceed 10 mg/dose or 40 mg/d
25 mg PR bid
Pediatric
Not established; problem rare <20 y
Coadministration with other CNS depressants or anticonvulsants may cause additive effects
Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe hypotension; children <2 years or <9 kg; severe liver or cardiac disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Drug-induced Parkinson syndrome or pseudoparkinsonism occurs frequently, akathisia is most common extrapyramidal reaction in elderly persons; tardive dyskinesia may occur, especially in elderly persons (up to 40%); extrapyramidal effects most pronounced in children <5 y or elderly persons; lowers seizure threshold, caution in patients with history of seizures; caution in patients with prostatic hypertrophy, peptic ulcer, dehydration, or history of neuroleptic malignant syndrome
Ondansetron (Zofran)
5-HT-3 receptor antagonist used when other classes fail or are contraindicated.
Adult
4 mg IV q6h prn; 8 mg PO tid prn
Pediatric
Not established
Although potential exists for cytochrome P-450 inducers (eg, barbiturates, rifampin, carbamazepine, phenytoin) to change half-life and clearance, dosage adjustment usually not required
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired liver function; medication administered for prevention of nausea and vomiting, not for rescue of nausea and vomiting
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
Jorgensen T. Abdominal symptoms and gallstone disease: an epidemiological investigation. Hepatology. 1989;9:856-60.
Targarona EM, Ayuso RM, Bordas JM, et al. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bileduct calculi in high-risk patients. Lancet. Apr 6 1996;347(9006):926-9. [Medline].
Davidson BR, Neoptolemos JP, Carr-Locke DL. Endoscopic sphincterotomy for common bile duct calculi in patients with gall bladder in situ considered unfit for surgery. Gut. Jan 1988;29(1):114-20. [Medline].
Stiegmann GV. Bile duct calculi--the new challenges. HPB Surg. 1998;10(6):409-10. [Medline].
Adams DB, Tarnasky PR, Hawes RH, et al. Outcome after laparoscopic cholecystectomy for chronic acalculous cholecystitis. Am Surg. Jan 1998;64(1):1-5; discussion 5-6. [Medline].
Akriviadis EA, Hatzigavriel M, Kapnias D, et al. Treatment of biliary colic with diclofenac: a randomized, double-blind, placebo-controlled study. Gastroenterology. Jul 1997;113(1):225-31. [Medline].
Amaral J, Xiao ZL, Chen Q, et al. Gallbladder muscle dysfunction in patients with chronic acalculous disease. Gastroenterology. Feb 2001;120(2):506-11. [Medline].
Attili AF, De Santis A, Capri R, et al. The natural history of gallstones: the GREPCO experience. The GREPCO Group. Hepatology. Mar 1995;21(3):655-60. [Medline].
Berger MY, van der Velden JJ, Lijmer JG, et al. Abdominal symptoms: do they predict gallstones? A systematic review. Scand J Gastroenterol. Jan 2000;35(1):70-6. [Medline].
Canfield AJ, Hetz SP, Schriver JP, et al. Biliary dyskinesia: a study of more than 200 patients and review of the literature. J Gastrointest Surg. Sep-Oct 1998;2(5):443-8. [Medline].
Carney DE, Kokoska ER, Grosfeld JL, et al. Predictors of successful outcome after cholecystectomy for biliary dyskinesia. J Pediatr Surg. Jun 2004;39(6):813-6; discussion 813-6. [Medline].
DiBaise JK, Oleynikov D. Does gallbladder ejection fraction predict outcome after cholecystectomy for suspected chronic acalculous gallbladder dysfunction? A systematic review. Am J Gastroenterol. Dec 2003;98(12):2605-11. [Medline].
Drossman DA. Rome II. The Functional Gastrointestinal Disorders. Diagnosis, Pathophysiology and Treatment: a Multination Consensus. Second edition. 2000.
Egbert AM. Gallstone symptoms. Myth and reality. Postgrad Med. Oct 1991;90(5):119-26. [Medline].
Fenster LF, Lonborg R, Thirlby RC, et al. What symptoms does cholecystectomy cure? Insights from an outcomes measurement project and review of the literature. Am J Surg. May 1995;169(5):533-8. [Medline].
Fenster LF, Lonborg R, Thirlby RC, et al. What symptoms does cholecystectomy cure? Insights from an outcomes measurement project and review of the literature. Am J Surg. May 1995;169(5):533-8. [Medline].
Glasgow RE, Cho M, Hutter MM, et al. The spectrum and cost of complicated gallstone disease in California. Arch Surg. Sep 2000;135(9):1021-5; discussion 1025-7. [Medline].
Gui GP, Cheruvu CV, West N, et al. Is cholecystectomy effective treatment for symptomatic gallstones? Clinical outcome after long-term follow-up. Ann R Coll Surg Engl. Jan 1998;80(1):25-32. [Medline].
Luman W, Adams WH, Nixon SN, et al. Incidence of persistent symptoms after laparoscopic cholecystectomy: a prospective study. Gut. Dec 1996;39(6):863-6. [Medline].
Patel NA, Lamb JJ, Hogle NJ, et al. Therapeutic efficacy of laparoscopic cholecystectomy in the treatment of biliary dyskinesia. Am J Surg. Feb 2004;187(2):209-12. [Medline].
Poggio JL, Rowland CM, Gores GJ, et al. A comparison of laparoscopic and open cholecystectomy in patients with compensated cirrhosis and symptomatic gallstone disease. Surgery. Apr 2000;127(4):405-11. [Medline].
Rolleston HD. Diseases of the Liver, Gall-Bladder and Bile Ducts. Philadelphia, Pa: WB Saunders; 1905..
Rutledge D, Jones D, Rege R. Consequences of delay in surgical treatment of biliary disease. Am J Surg. Dec 2000;180(6):466-9. [Medline].
Schiff ER, Sorrell MF, Maddrey WC, eds. Schiff's Diseases of the Liver. Vol 1. 8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1998.
Scott TR, Zucker KA, Bailey RW. Laparoscopic cholecystectomy: a review of 12,397 patients. Surg Laparosc Endosc. Sep 1992;2(3):191-8. [Medline].
Siddiqui S, Newbrough S, Alterman D, et al. Efficacy of laparoscopic cholecystectomy in the pediatric population. J Pediatr Surg. Jan 2008;43(1):109-13; discussion 113. [Medline].
Sorenson MK, Fancher S, Lang NP, et al. Abnormal gallbladder nuclear ejection fraction predicts success of cholecystectomy in patients with biliary dyskinesia. Am J Surg. Dec 1993;166(6):672-4; discussion 674-5. [Medline].
Steinberg WM. Sphincter of Oddi dysfunction: a clinical controversy. Gastroenterology. Nov 1988;95(5):1409-15. [Medline].
Tadataka Y, Alpers DH, Laine L et al, eds. Textbook of Gastroenterology. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999.
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
