Biliary Colic

Right Upper Abdominal Pain Caused By Gall Bladder Stone Impaction

Biliary colic or gallstone pain, refers to the intermittent right upper abdominal pain that results from the contraction of the gallbladder in a bid to expel either a gallstone or sludge blocking the lumen of the gallbladder or the duct that connects it to the small intestine. The pain is not a true colic. When it comes on, it could persist for minutes to hours, with periods of increased severity and then goes away. See  what causes gallstone pain, how to diagnose it and best treatment options available today.  

You woke up suddenly at night or even minutes to a few hours after having a meal with pain on the right upper abdomen. Initially you wondered if this is wind or muscle pain or something else. Within minutes, the pain becomes more intense.

It is there. Localized to just under or around your right breast. The pain continues to worsen and spreads like a squeezing pain or stabbing knife through the right side of  your lower chest and upper abdomen towards your back.

The pain may also spread up to the tip of your right shoulder or down to the bottom of your right shoulder blade bone behind.

You walk about or roll around, looking for a position of comfort, or even coiling up to help ease the pain.

Nauseated. You may actually vomit, and sweating like you never have before.

What is this? Could I be having a heart attack? Or is it something that I have eaten? As you pace around looking for help, the pain gradually subsides and after a few more minutes to hours, you are completely pain free. God! What is this?

It sounds like you might have just had an attack of biliary colic or gallstone pain. Gall stones? Let's see what they are and why they cause so much trouble, who gets it, risk factors, how it is diagnosed and treatment options available.

The Gallbladder, Gallstones And How Stones Are Formed

The gallbladder is a pear shaped sac lying just under the right half of the liver.

It is where bile, that green bitter liquid we find in our vomit, is stored. It has a narrow part that joins the liver ducts and those of the pancreas, before they continue as a single drainage duct into the small intestine.

The liver produces about 500 to 1500mLs of bile every day. Some of this amount drains directly into the small intestines where it helps to emulsify or break down fat in our meals into water soluble material for easy digestion.

The remainder amount of bile is stored away in the gallbladder. The gallbladder concentrates the bile about ten times stronger than it was originally. If the bile gets over concentrated, crystals start to form in the solution, leading to stone formation.

This stone is what is referred to as gall stone.

Gall stones could be anything from the size of grains of sands up to tennis ball size. They could be only a few in some people to several hundreds lodged inside the gallbladder.

We have included a picture to the right of this paragraph, of a bottle filled with gallstones from one patient. He has been suffering with pain on his right upper abdomen for many months before a scan result identified his pain to be due to bilary colic or gallstones.

There are three types of gallstones. The type of gallstones you form will depend a lot on your diet.The three types of stones are:

  • Cholesterol stones
  • Pigment stones
  • Mixed stones

In the United Kingdom and other affluent industrialized western countries, cholesterol stones are most prevalent. This is mainly because of high fat diet. In poor countries, pigment stones are more common.

Cholesterol stones, as the name suggests, contains cholesterol mainly. Pigment stones contain bilirubin salts (e.g. Calcium bilirubinate).

Up to 15 out of every 100 persons form stones in their gallbladder, and most times, these stones do not cause any problem. In the United States, over 20 million people have gallstones. 80 – 90 % of these are cholesterol stones. This situation is similar in other western countries. One in five women and one in eight men have gallbladder stones.

Risk Factors For Gallstone Formation

Women are twic emore likely to develop gallstones than men. If you eat fat rich food and diary products, you are also more likely to have gallstones. 

The following are other risk factors for developing gallstones. They include:

  • Being female, fair, fat, fertile of forty or fifty-something years of age and of Northern European origin, it is most likely that you will develop gallstones than anyone else.
  • It is also common amongst Pima Indians, North Americans and Chileans.
  • Generally Japanese have the lowest incidence of stones.
  • Sudden weight loss,
  • Prolonged fasting,
  • Pregnancy,
  • Presence of Crohns disease,
  • Cystic fibrosis,
  • Diabetes,
  • Liver cirrhosis,
  • Sickle disease,
  • Thalassamia,
  • Ageing
  • Extensive bowel resection,
  • Use of certain medications like oral contraceptive pills, chlopromazine ( largactil), octreotide, and clofibrate will also increase the chances of developing gallstones.

GallBladder Diseases

Biliary colic or gallstone pain, gallstone sludge, cholecystitis, gallstone pancreatitis and gallstone ileus, are all a continuum in the spectrum of conditions referred to as gallstone or gall bladder diseases. Understanding how they relate would help in understanding the possible problems and complications that could arise from having gallstones.

Most gallstones in the gallbladder do not cause any problem.

In fact it is estimated that up to 80% of people who carry stones in their gallbladder do not know that they do and have no symptoms whatsoever.

Such stones are referred to as silent stones.

They may be accidentally picked up by ultrasound scan during investigation of the abdomen for other reasons. Such silent stones that are not causing any problem are better left alone.

When stones from the gallbladder move into and block the tubes or collecting systems or ducts of the gallbladder without an associated infection going on in the gallbladder, the affected duct goes into spasm in an attempt to expel the stone. This causes biliary colic as described above. This is due to gallstones alone.

If the stone irritates the wall of the gallbladder, either because of its size, or from prolonged contact and impaction for more than 6 hours, plus invasion by bacteria, this could lead to the development of a disease of the gallbladder called Cholecystitis. This is gallstones plus gallbladder infection.

The gallstones could also move to block the narrow passage way at the neck of the gallbladder, or smaller stones could migrate out into the collecting system of the liver or into the pancreatic ducts and small intestines. Gallstones in the pancreatic duct will lead to gallstone pancreatitis. This is due to gallstones causing back flow or back up into the pancreas, leading to inflammation of the pancreas and severe central upper abdominal pain and vomiting.

When gallstones find their way into the small intestines, they could cause the small bowel from working in what is referred to as gallstone ileus.

Pus collecting in the gallbladder leads to gallbladder empyema. If not relieved, the gallbladder could rupture.

Prolonged irritation of the gallbladder could lead to cancer of the gallbladder.

Symptoms of Biliary Colic

The typical story of biliary colic is one of sudden or insidious onset right upper quadrant abdominal pain "from the blues". It may follow a heavy meal or 1 to 2 hours after a fatty or fried meal. It could start and wake patient up at night. Any time.

  • Biliary colic or gallstone pain classically starts in the upper abdomen above the umbilicus called the epigastrium, and or move to the right upper abdomen called the right upper quadrant.
  • It may spread to the back like cholecystitis, and most people describe the pain as crushing, band-like, and may also spread to the right upper arm. Unlike sudden pain from heart origin, biliary colic pain does not spread to the left arm.
  • Pain may radiate to the right shoulder tip or to the tip of the shoulder blade bone on the back.

One thing that differentiate biliary colic from cholecystitis, is that the pain usually resolve on time, and there is not an associated fever.

The pain may come back after a while, but patients usually feel well in between (during pain free periods).

There may be vomiting during the height of pain, and patient may try adopting various positions and rolling on the floor in a bid to alleviate the sufferings.

If the stone is successfully expelled from the duct where it is impacted, the pain may resolve and not come back on.

Diagnosis

The diagnosis of biliary colic is mainly based on the story from the patient and examination findings.

  • Where biliary colic is suspected, the best and single investigation is to do an abdominal ultrasound scan.
  • HIDA Scan is also undertaken in North America.
  • Other investigations could include plain abdominal radiography (x-ray), ERCP, MRCP, or oral cholecystography.
  • Blood work is often done and would include a complete or full blood count to ascertain or exclude presence of infection, electrolytes and urea or BUN levels to exclude dehydration and derangement of the body salts, CRP to see if there is evidence of significant inflammation or infection, and Amylase or Lactate Dehydrogenase to determine if the pancreas is involved in the inflammatory process.

Treatment of Biliary Colic

The treatment options for bilary colic include:

  • Use of moderate to severe pain killers like Naproxen and cocodamol 15/500mg combination (cocodamol in the UK is the same as Tylenol 3 or Tylenol 4 if you are in North America) to deal with the gallstone pain relief immediately.
  • Acupuncture. There are lot of scientific evidence to show that well targeted acupuncture could help dislodge gallstones from the gallbladder and watched under ultrasound imaging in up to 15% of patients. This technique is common in China, but rarely used in Western medicine.
  • Use of oral medications referred to as bile salts to dissolve and expel the stones, like Ursodiol or ursodeoxycholic acid also abbreviated UDCA, if surgery is considered unsafe. Some would even try this option first before proceeding to the surgical route. A dose of 300mg daily or twice a day depending on weight, taken for months is often prescribed by gastroenterologists who have made the decision to treat gallstones with tablets. This could takes a long time to clear the stones - months or years and it is never prescribed if you are having severe pain and need surgery.
  • Shock Wave Lithotripsy. This is the use of ultrasound wave in a special setting to fragment the stones and then have it passed out. It is very much like what is used in treating kidney stones too. Only a few centers offer this form of treatment in the United Kingdom.
  • Open or Laparoscopic Cholecystectomy. This is the surgical removal of the  gall bladder with the stone. It is the sure and best known method for treatment of gallstone problems. 
  • Use of a keyhole technique to release the sphincter of the gall bladder duct and pick out the stones, or let the stones "flow out", in a procedure referred to as endoscopic retrograde choliangiopancreatography or ERCP for short. Where there is a stricture or narrowing down the bile passages, the surgeon can widen or dilate such in a procedure we call sphincterotomy. ERCP is used for pancreatic problems too.

In a small number of individuals, despite suffering with all the features of biliary colic, scans may demonstrate no stone in their gallbladder. If they nevertheless notice that consumption of fatty food triggers pain as described above, going on a low fat gallstone diet for gallstone sufferers may bring them relief.

Have A Concern or Comment About Gall Bladder Stone & Bilairy Colic?

Right upper abdominal pain? Think it might be due to biliary colic? Or have you been diagnosed with biliary colic in the past? Any great story or experience on this or related topic? Share it!

Please feel free to leave comments here too, if you read postings by others, and you want to make a contribution.

All postings are read by the abdominal pain team, and we shall respond to some queries directly on this page too.

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