Biliary colic is a common presentation of a stone in the cystic duct or common bile duct of the biliary tree. Colic refers to the type of pain that "comes and goes," typically after eating a large, fatty meal which causes contraction of the gallbladder. However, the pain is usually constant and not colicky.

History and Physical Examinations

The pain is usually in the Right Upper Quadrant (RUQ) of the abdomen and may have radiation into the back. With uncomplicated biliary colic, patients will likely present only with pain. However, some may also report nausea and/or vomiting. These symptoms are accentuated after meals.

Biliary colic patients are afebrile and will commonly have no abnormal vitals in contrast to acute cholecystitis or cholangitis, which may present with fevers, tachycardia, or even hypotension if they progress to septic shock.

Patients with biliary colic will generally only have right upper quadrant (RUQ) or epigastric tenderness on physical exam. Abdominal distension and rebound tenderness are less common. Jaundice is not seen with blockage of the cystic duct; however, it is common with blockage of the common bile duct due to an elevation of direct bilirubin. This finding would suggest a more serious obstruction of the biliary tree and should raise suspicion for potential cholangitis rather than biliary colic.

Evaluation of biliary colic

Laboratory tests to be ordered include a complete blood count (CBC) and a metabolic panel with liver function tests. It is important to have these tests to rule out more serious gallbladder pathology such as acute cholecystitis or cholangitis.

RUQ abdominal ultrasound is the first radiologic test to evaluate suspected biliary pathology.

MRCP may be used for better visualization of the biliary tree, especially when evaluating for choledocholithiasis.

Endoscopic retrograde cholangiopancreatography (ERCP) can be used to evaluate for common bile duct stones if all other imaging is equivocal.

Management of biliary colic

Medical management of biliary colic involves strict maintenance of a low-fat diet and supportive management with antiemetics and pain control, however since patients typically have multiple stones the risk for recurrence of their biliary colic is high.

There is no role for antibiotics in biliary colic as there is no infectious etiology, such as in acute cholecystitis or cholangitis.

Oral ursodeoxycholic acid has also been used to help dissolve gallstones.

Surgical intervention with laparoscopic cholecystectomy remains the gold standard.

In patients who are poor surgical candidates, extracorporeal shockwave lithotripsy may be considered, but there is a considerable chance of stone recurrence. Open cholecystectomy is a less common approach, used in patients who are not candidates for laparoscopic surgery.

Endoscopic retrograde cholangiopancreatography (ERCP) is both diagnostic and therapeutic for common bile duct stones.

Patients with biliary colic may be treated symptomatically with a low-fat diet, pain control, and anti-emetics, and follow up for a laparoscopic cholecystectomy as an outpatient within a reasonable time-frame.