Biliary colic

Biliary colic is due to a stone passing through the cystic duct or impacted in it. The patient has a severe colicky epigastric pain which radiates to his right subcostal region and right scapula. He wants to bend himself double, he rolls around, and rarely keeps still. Intense pain comes in waves against a background of severe pain, typically in attacks lasting about half an hour, one to three hours after a fatty meal. Pain makes his breathing difficult and may be accompanied by nausea and vomiting. Attacks occasionally last as long as 6 hours. If they last 24 hours, he has cholecystitis, not uncomplicated biliary colic. He may be tender in his hypochondrium or his right epigastrium, and have a positive Murphy's sign (see below).

BILIARY COLIC MURPHY'S SIGN. Put your hand under the patient's ribs on the right side, and ask him to take a deep breath. If he feels pain as his gall-bladder moves down on to your hand, the sign is positive and indicates cholecystitis.

X-RAYS. Most gallstones don't show on an X-ray, so a plain film is unlikely to help. An oral cholecystogram will show 90% of stones, provided he is not jaundiced; if he is clinically jaundiced you won't get good X-rays. Look for: (1) the negative shadows of gallstones floating in the contrast medium, (2) no outline to his gall-bladder, showing that his cystic duct is blocked, or his gall-bladder is severely diseased. If his symptoms are suggestive, repeat the test with a double dose of contrast medium.

ULTRASOUND is a simple, cheap and accurate way of finding stones in the gall-bladder, whether or not he is jaundiced; it is better than a cholecystogram, but it needs skill.

SPECIAL TESTS. A slightly raised serum bilirubin may indicate subclinical jaundice. Occasionally, only his serum alkaline phosphatase is raised when his bile duct is obstructed.

THE DIFFERENTIAL DIAGNOSIS OF BILIARY COLIC includes a perforated peptic ulcer (11.2), an amoebic liver abscess (31.12), and upper small gut obstruction (10.3).

Suggesting ureteric colic[md]pain radiating towards the genitalia. Blood in the patient's urine on microscopic examination. Radio-opaque shadows along the line of his ureter.

Suggesting right basal pneumonia[md]cough, fever, and lung signs at his right base.

THE NON-OPERATIVE TREATMENT OF BILIARY COLIC. If necessary, give him pethidine 50 to 100 mg 4-hourly intravenously or intramuscularly, for 24 to 48 hours. An anticholinergic drug is optional.

Give him only clear fluids by mouth. If he vomits, give him fluids intravenously.

If he is fortunate, his pain will stop in 24 to 48 hours, and you can start to feed him cautiously, avoiding oily or fatty foods. Start to investigate him as soon as he has recovered from his pain. Advise him to take a low-fat diet.