Image of the Day 13: Biliary Colic With Cholelithiasis

A 45 year old lady, P4, LNMP 1/52 prior to presentation presented with right hypochondriac pain 2 hours prior to presentation. She described the pain as a dull aching pain, constant, radiating to the right scapula and pain score of 6/5.

On further questioning, she admit that having the similar pain for the past 2 years ago about 2-3 attack per year but never seek treatment because she able to tolerate the pain. There was no history of yellowish discoloration of sclera, no fever with chills and rigor, no chest pain, shortness of breath, palpitation and no acid reflux symptoms.

Physical examination reveals tenderness upon deep palpation at right hypochondriac region. No hepatospleenomegally and no mass palpable.

The result of full blood count, coagulation studies, renal and liver function test are uneventful. Abdominal X ray shows no abnormality.

Her ultrasound abdomen is normal except for a present of stone inside the gall bladder with positive acoustic shadow. The gallbladder is not dilated, no thickening of gallbladder wall and no pericystic fluid collection. The visualize part of common bile duct shows no dilatation.

Discussion

This case illustrate a typical presentation of patient with biliary colic associated with cholelithiasis. It is important to elicit a detail history and thorough examination as biliary tract disease can range in spectrum from incidental finding of asymptomatic gallstone to biliary colic, cholecystitis, choledocholithiasis and life threatening condition like ascending cholangitis, abscess, gall bladder perforation and gall bladder gangrene.

Gallstone can be formed from cholesterol (80%), pigment stone (20%) and minority of them will have a mix stone. The asymptomatic gallstone problem may temporarily obstruct the cystic duct or pass through the common bile duct to give rise of symptomatic biliary colic like this case.

The risk factor for gallstone disease are being describe as the traditional 4F namely Fair, Female, Fat and Fertile. Other risk factor includes pregnancy, elderly, weight loss, liver transplant patient, oral contraceptive/ estrogen replacement, ocreotide and ceftriaxone

Typical presentation of biliary colic is a persistent constant pain up to 1-5 hours located at the epigastrium or right upper quadrant region. It is described as severe dull aching pain which may radiate to the right scapula or back. Pain is often develop hours after meal and relieve by moving around. The attack usually occurs at night and awaken them from sleep. Some patient may also develop nausea, vomiting, fever and pleuritic pain.

Before diagnosing it as biliary colic, it is very important to elicit a life threatening condition especially inferior myocardial infarction. Therefore, it is a good practice to perform an ECG particularly in high risk group for acute coronary syndrome. Apart from the spectrum of biliary tract disease, other differential includes basal pneumonia, gastritis, gastroesophageal reflux, and liver related problem.

Basic blood panel is normal in biliary colic and cholelithiasis. Abnormal finding of liver function test should raise a suspiciousness of more serious pathology like cholangitis, choledocholithiasis, Mirizzi syndrome, hepatitis or any other cause for obstructive jaundice. Depending on clincial judgment upon attending the patient, serum amylase and calcium level might be needed to exclude pancreatitis.

While hepatobiliary system ultrasound is the most important diagnostic imaging modality, Abdominal X Ray can be particularly helpful as minority of the patient will have an opacity in the gallbladder region.  

Hepatic 2,6-dimethyliminodiacetic acid (HIDA) scans and diisopropyl iminodiacetic acid (DISIDA) are functional studies of the gallbladder and usually reserve for chronic cholecystitis or when there is a dilemma in making diagnosis. The same thing goes to CT Scan. Endoscopic Retrograde Cholangiopancreatography (ERCP) is not without a risk and therefore should be reserved until there is a high potential for intervention.

Pain management is the priority in managing the patient with biliary colic in emergency department setting. The choices of analgesic should be based on pain score. Opiate analgesic is the best option for moderate to severe pain. However, morphine should be avoided as it increase the tone of sphincter of oddi. Anticholinergic antispasmodics and anti inflammatory may also be used in mild to moderate pain. Apart from that, medical management aiming for symptom relieving like anti emetic should also be instituted.

Stable patient can be discharge with appointment under surgical outpatient clinic for further management of cholelithiasis. Oral dissolution therapy using ursodeoxycholic acid can be prescribed and may hep to dissolve small gallstone. Patient should also be advised to reduce fat containing food, taking adequate of water and weight reduction. In Surgical Outpatient clinic, depending on patient condition; it can be managed conservatively or an appointment for surgical intervention (laparoscopic or open cholecystectomy).

Reference

1) Douglas M Heuman, "Cholelithiasis", eMedicine.

http://emedicine.medscape.com/article/175667

2)  Peter A D Steel, " Cholecystitis and Biliary Colic in Emergency Medicine" eMedicine

http://emedicine.medscape.com/article/1950020