SIGNS AND SYMPTOMS 
History
- Dull, aching epigastric or right upper quadrant (RUQ) pain:
- Arising over 2–3 min, continuous (rather than colicky), and lasting from 30 min–6 hr before dissipating
- May radiate to the tip of right scapula, acromion, or thoracic spine
- Often correlated with ingestion of large, fatty meal
- Anorexia
- Nausea and vomiting
- Afebrile:
Physical Exam
- Tenderness to deep palpation but without rebound
- Murphy sign (inspiratory arrest during deep palpation of the RUQ) may be present during the episode of colic, but should resolve when symptoms pass.
ESSENTIAL WORKUP
DIAGNOSIS TESTS & INTERPRETATION
Lab
- CBC:
- WBC count usually normal, but may elevate after vomiting
- Leukocytosis suggestive of cholecystitis or cholangitis
- LFTs:
- Usually normal
- Elevation suggests common duct obstruction, cholangitis, cholecystitis, or hepatitis.
- Amylase/lipase
- Normal or minimally elevated with passage of gallstone
- Elevation in context of severe persistent epigastric pain suggests pancreatitis.
- Urinalysis:
- Exclude nephrolithiasis or pyelonephritis.
- Bilirubinuria suggests common duct obstruction or hepatitis.
Imaging
- US:
- Detects gallstones with sensitivity and specificity > 90%
- Dilation of common bile duct > 10 mm indicates obstruction, but no dilation may be present with acute obstruction.
- Gallbladder wall thickening > 5 mm or pericolic fluid 90% sensitive and 80% specific for cholecystitis
- Accuracy enhanced in fasting patient (> 6 hr) with noncontracted gallbladder
- Radionuclide scanning (HIDA):
- Cannot detect gallstones
- Passage of tracer into small intestine without visualization of gallbladder highly diagnostic of cystic duct obstruction and cholecystitis:
- Sensitivity and specificity roughly 95%
- Failure of tracer to pass into duodenum suggests common bile duct obstruction. Accuracy enhanced by morphine injection during scan causing sphincter of Oddi spasm and improving gallbladder filling.
- CT scanning:
- Less sensitive than US to detect gallstones:
- Most useful to exclude other causes of upper abdominal pain such as aortic aneurysm, perihepatic abscess, or pancreatic pseudocyst
- Detects rare complications such as air in gallbladder wall in emphysematous cholecystitis, air-filled gallbladder in biliary-enteric fistula or a "Porcelain gallbladder."
- Plain radiographs:
- Most useful for diagnosis of intestinal obstruction or rare abnormalities such as air in gallbladder wall in emphysematous cholecystitis, air-filled gallbladder in biliary-enteric fistula or a "Porcelain gallbladder."
DIFFERENTIAL DIAGNOSIS
[Outline]
PRE-HOSPITAL
Initiate IV access for patients with nausea or vomiting.
INITIAL STABILIZATION/THERAPY
IV fluid bolus if vomiting or hypotensive
ED TREATMENT/PROCEDURES
- IV hydration with 0.9% NS if vomiting
- NPO
- Parenteral NSAIDs (ketorolac) may lessen biliary spasm, but may exacerbate peptic causes of pain.
- Narcotic analgesics (hydromorphone) with antiemetic (ondansetron):
- Administer for refractory pain once diagnosis is reasonably established.
- Morphine sulfate may lead to spasm at sphincter of Oddi (clinical significance not well established).
- Anticholinergics (glycopyrrolate) have no proven benefit in the treatment of acute biliary pain.
MEDICATION
- Ketorolac: 60 mg IM or 30 mg (peds: Start 0.5 mg/kg for 1st dose up to 1 mg/kg/24h) IV q6h. In elderly: 30 mg IM or 15 mg IV
- Hydromorphone: 0.5–2 mg IV (0.01–0.02 mg/kg), titrated to pain relief.
- Ondansetron: 4–8 mg IV (0.15–0.3 mg/kg) IV (not to exceed 8 mg/dose IV), q4h PRN vomiting.
[Outline]
DISPOSITION
Admission Criteria
Admission and surgical or gastroenterologic consultation for evidence of:
- Acute cholecystitis
- Acute cholangitis
- Common duct obstruction
- Gallstone pancreatitis
Discharge Criteria
- Lack of clinical, lab, or radiographic evidence of cholecystitis, cholangitis, common duct obstruction, or pancreatitis
- Resolution of all pain and tenderness
- Ability to tolerate oral fluids
Issues for Referral
- General surgery referral for all cases of biliary colic with documented cholelithiasis or for radiographic finding of a "Porcelain gallbladder" (due to increased risk of gallbladder carcinoma).
- GI referral for choledocholithiasis.
FOLLOW-UP RECOMMENDATIONS
Surgical follow-up for patients with symptomatic gallstones
[Outline]
- Antevil JL, Buckley RG, Johnson AS, et al. Treatment of suspected symptomatic cholelithiasis with glycopyrrolate: A prospective, randomized clinical trial. Ann Emerg Med. 2005;45:172–176.
- Jackson PG, Evans SR. Biliary system. In: Townsend CM Jr, ed. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: WB Saunders; 2012:1476–1514.
- Silen W, ed. The colics. Cope's Early Diagnosis of the Acute Abdomen. 22nd ed. Oxford, UK: Oxford University Press; 2010:145–153.
- Strasberg SM. Acute calculous cholecystitis. N Eng J Med. 2008;358:2804–2811.
- Vassiliou MC, Laycock WS. Biliary Dyskinesia. Surg Clin North Am. 2008;88(6):1253–1272.
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