An Overview of Biliary Colic

When Gallstones Start Causing Symptoms

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Biliary colic is a type of abdominal pain caused by a temporary blockage in the ducts leading out from the gallbladder. Sometimes, but not always, people who have gallstones get biliary colic. The word “colic” refers to the way the pain sometimes starts and stops abruptly, and “biliary” refers to bile or the bile ducts. Biliary colic is also known as a “gallstone attack” or a “gallbladder attack.”

Symptoms

Biliary colic is a type of pain that usually occurs in the upper part of your belly (abdomen), usually a little to the right or centrally. In some people, it feels like the pain is radiating to their back or their right shoulder.

The pain usually begins suddenly. Once it begins, it’s usually a moderate, steady pain. Most commonly, an episode of biliary colic happens within a couple of hours after a person has eaten a meal, often a large meal with a lot of fat. Unlike some other kinds of abdominal pain, biliary colic doesn’t improve after having a bowel movement.

Usually the worst of the pain happens about an hour after it starts. Typically, the pain gradually goes away over one to five hours (as the gallstone moves out of the duct).

However, the symptoms of biliary colic don’t always follow this pattern. For example, you might have different patterns in the location and pattern of the pain.

Most of the time, people with biliary colic don’t have additional symptoms (though nausea and vomiting do sometimes happen). For example, a person who has a fever is unlikely to be having symptoms from biliary colic.

If the pain persists, or if you have a fever, you might not be experiencing biliary colic but complications from your gallstones. For example, some people with gallstones get cholecystitis (inflammation of the gallbladder), pancreatitis (inflammation of the pancreas), or cholangitis (infection of the biliary tract).

When to Get Prompt Medical Attention

Seek prompt medical attention if you have the following:

  • Severe pain
  • Pain with vomiting
  • Pain with fever
  • Pain that persists for several hours
  • Jaundice (yellowed skin)
  • Darkened urine 

Most people continue to have episodes of biliary colic unless they receive treatment. Of people who have a first attack of biliary colic, over 90% will have at least another episode within ten years.

Causes

The Gallbladder, Bile, and the Biliary Tree

To understand what causes biliary colic, it’s helpful to understand a little about the gallbladder and its ducts (called the “biliary tree”).

The gallbladder is a small sac-like organ that sits underneath the liver. The liver produces bile, some of which is stored in the gallbladder. Bile is a thick, green liquid that helps your body digest foods and some kinds of vitamins. Bile exits the gallbladder through a thin duct (the cystic duct) that leads to another duct (the common bile duct). Eventually, this duct empties into part of the small intestine, where the bile can aid in the digestion and absorption of nutrients.

During a meal, various physiological signals make the gallbladder squeeze. This helps get the bile down the biliary tract. A bigger, fattier meal may trigger the gallbladder to squeeze harder.

Normally, this squeezing isn’t a problem. But it can be a problem if your gallbladder starts to squeeze and something is temporarily blocking the biliary ducts. If that happens, it can lead to the symptoms of biliary colic.

Biliary colic can be caused by anything that temporarily blocks the biliary ducts, especially the cystic duct. Most often, a gallstone is the culprit. However, biliary colic can also be caused by a biliary stricture, a part of the bile duct that has become much smaller inside. This might happen, for example, from injury during surgery, pancreatitis, or from certain other medical conditions. A tumor might also block the duct, leading to symptoms of biliary colic. However, gallstones are by far the most common cause of a block in the biliary ducts causing biliary colic.

Gallstones

Sometimes the bile becomes thick and hardened and forms gallstones (also called “cholelithiasis”). Sometimes gallstones form when the bile contains too much cholesterol or too much bilirubin (a normal breakdown product of hemoglobin). Researchers are still learning about what causes gallstones to form in some people but not in others. Different types of gallstones have some different risk factors, depending on the composition of the stones. The most common type are cholesterol stones.

Some risk factors for gallstones include the following:

  • Pregnancy and having had multiple children
  • Female sex
  • Age of 40 or older
  • Rapid weight loss
  • Obesity
  • Family history of gallstones
  • Certain ethnic backgrounds (e.g., Native Americans)
  • Certain diseases with lots of breakdown of red blood cells (e.g., sickle cell disease)

However, some people get gallstones even without having any of these risk factors.

Though gallstones are the most common cause of biliary colic, it’s important to realize that most people with gallstones don’t ever experience biliary colic or other complications. Most people who have gallstones never experience any symptoms from them.

Diagnosis

Diagnosis begins with a full medical history and clinical exam. Your clinician will ask you about your symptoms and about your other medical conditions. You’ll also need a physical exam, including a thorough exam of your abdomen. For biliary colic, the abdominal exam is usually normal, except for some possible upper abdominal tenderness. It’s especially important that your clinician check you for signs of infection (like fever) or yellowed skin (jaundice). This might signal a more serious problem.

Depending on the circumstances, medical history and clinical exam might be enough to diagnose biliary colic, especially if you already know that you have gallstones, or if you’ve had an episode of biliary colic before. However, your clinician also needs to distinguish biliary colic from other conditions that can have some overlapping symptoms, like pancreatitis or appendicitis. Some of these conditions need prompt medical interventions, such as surgery.

Other types of complications from gallstones might need to be considered as well. For example, acute cholecystitis (infection of the gallbladder) is a more serious condition than biliary colic, and it might require hospitalization. Cholangitis (infection of the gallbladder ducts) is another potentially serious condition that can occur due to gallstones.

If you’ve had an episode of biliary colic before, and this feels similar, you might not need to see your health care provider right away. That may be OK if you aren’t having prolonged or extreme symptoms, fever, jaundice, or other additional issues. If you are at all uncertain if you are having an episode of biliary colic, it’s best to see your health care provider promptly.

Imaging

You might already know that you have gallstones. For example, they might have been seen on a type of imaging test done for another reason. If so, you might not need additional imaging.

However, if you are not sure if you have gallstones, or if your practitioner is worried about a different cause of your symptoms, you might need some imaging tests. An ultrasound of your abdomen is often the first place medical practitioners start, as it is an inexpensive and noninvasive test.

In some situations, you might need additional testing. That might include some of the imaging modalities like the following:

These may help diagnose biliary colic and eliminate other possibilities.

Laboratory Tests

Laboratory tests are also sometimes helpful in diagnosing biliary colic and in ruling out other potential causes. Some common blood tests you might need are:

  • Complete blood count (CBC)
  • Metabolic panel, including tests of liver function (e.g., ALT)
  • Tests of pancreas injury (e.g., amylase)

These tests are also particularly important in making sure another more serious medical issue isn’t the problem.

Treatment

Management of a Biliary Colic Episode

During an episode of biliary colic, pain control is the cornerstone of treatment. Most commonly, this will mean some type of nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen. Other aspects of treatment might include:

  • Antispasmodic agents (like scopolamine) which might reduce gallbladder spasms
  • Antiemetic drugs (to reduce nausea)
  • Fasting

Antibiotics do not help in treating biliary colic, since no underlying infection is present. Depending on the situation, you might or might not need hospitalization while you recover from your symptoms.

Longer Term Management

If you’ve had an episode of biliary colic, you are likely to have one again in the future. You have two main options for managing your symptoms. You can manage your condition with diet (and potentially with medication). Or you can opt to have your gallbladder surgically removed.

Surgery

Most commonly, clinicians recommend surgical removal of the gallbladder (cholecystectomy) in people who have had biliary colic. (But if you have gallstones without biliary colic, this is not the standard recommendation.) The good news is that because the gallbladder just stores bile and doesn’t have any other important jobs, its removal isn’t usually a serious problem. (Your liver will still continue to make bile that you can use for digestion.)

Surgery is the only definitive way to address the symptoms of biliary colic. Typically, it’s recommended that this surgery been done laparoscopically, using the help of special tools and cameras. This is a type of surgery uses smaller incisions compared to a laparotomy, the older surgical option which employs larger cuts through the wall of the abdomen. There are also other types of surgery that use smaller incisions but don’t use laparoscopic tools. Compared to laparotomy, these more minimally invasive surgeries may result in shorter hospital stays and faster recovery, but they may not be an option for everyone.

Laparoscopic removal of the gallbladder is the most commonly performed abdominal surgery in the United States. Most people have good results from it. However, some people do experience some serious side effects which might need follow-up treatment, like bile leak or injury to the bile duct. And surgery might be riskier if you have certain other medical conditions, or if you are pregnant. Particularly in these cases, you might want to consider non-surgical options first.

Non-surgical Approaches

You can try to manage your condition by sticking to a low-fat diet. In theory, this might reduce the likelihood that you’ll have a future episode of biliary colic.

Sometimes oral medications like ursodeoxycholic acid can be used to help dissolve gallstones. However, they take a long time to work, and they don’t work on all stone types. Also, new gallstones may still be formed.

Another potential option is something called “extracorporeal shock wave lithotripsy.” This technique uses high-energy shock waves to try and break up the stone. But this isn’t an option for all stones, and it isn’t always effective. Gallstones also sometimes come back with this method.

Do people tend to do better if they have surgery right after an initial episode of biliary colic or if they take a “wait and see” approach? We don’t have a lot of good data about this. Very limited evidence suggests that going ahead with surgery might decrease the length of hospital stays and the risk of complications. However, there are a lot of factors involved. You will need to work with your health care provider to make the best choice for you.

A Word From Verywell

Biliary colic can be a painful and annoying condition. However, it’s less serious than some other problems that can be caused by gallstones. Fortunately, surgical removal of the gallbladder will be a good option for many people. You might feel better just knowing that your biliary colic can never come back, after your gallbladder is removed. Work with your health care provider to weigh the benefits and possible risks in your particular situation. 

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Article Sources

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