Biliary Colic
Content
Morning Report April 1, 2013 2013 Holly Shillington, MD, PGY-3
The Case 18 year old Hispanic female in continuity clinic with abdominal pain.
She has had intermittent abdominal pain since September, but was started on omeprazole in January for heartburn and that pain has since resolved.
This pain episode seems different from her prior episodes of pain (specifically - different location and duration).
Pain started last night after dinner and has continued on and off for the past 20 hours.
Location: RUQ, sometimes moves up and down.
7/10 pain, “squeezing”.
Worse with eating and deep breathing.
No change with activity, bowel movements, or copious amounts of pepto bismol.
Associated nausea and vomiting (NBNB).
Stooling: Usually stools daily (sometimes hard, sometimes soft), but had loose stools yesterday.
Diet: Eats a lot of fast food.
ROS Negative except for abdominal pain, diarrhea, rhinorrhea, sore throat. No fever!
PMH: PCOS, acne, obesity, heartburn
Meds: omeprazole, OCP, Retin A
NKDA
IMMS: UTD
Family Hx: no gallstones or kidney stones
Social: Lives with Mom, Mom’s fiancé, and brother. Planning on graduating high school this May and starting at a local university in the Fall.
Teen Only Interview Never been sexually active. LMP one week ago. Denies verbal, physical, sexual abuse. Denies drug use. No other concerns from patient.
Physical Exam
Completely normal vitals and exam except: Obesity Black tongue Mild RUQ tenderness to palpation
Pepto Bismol!
DDX of Acute Abdominal Pain
GI
Renal Renal stone UTI
GYN Pregnancy PID Ruptured ovarian cyst Ovarian Torsion
Appendicitis Peptic Ulcer Disease Constipation Gastroenteritis
*More specific to the RUQ* Gallstones/Biliary Colic Cholecystitis Hepatitis Pancreatitis
Follow up
Friday:
Alk phos: 112 112 (nl)
GGT 594 (abnl) (nl 21-101)
Sunday: continued pain…
Ordered hepatitis panel, CMV, EBV, total/direct bili
Ordered U/S
AST 217 (abnl) (abnl) (nl 12-32)
ALT 224 (abnl) (nl 5-32) 5-32)
Amylase 33 (nl) (nl)
Lipase 33 (nl)
Monday:
U/S: Cholelithiasis w/o evidence of cholecystitis.
No Murphy’s Sign
Risk Factors for Gallstones
4 Fs: female, > 40, fat, fertile* *Estrogen increases cholesterol secretion and progesterone reduces bile acid secretion leading to supersaturation of the bile with cholesterol which promotes stone formation. Progesterone also slows gallbladder emptying leading to bile stasis.
Risk Factors for Gallstones
Estrogen replacement therapy in post-menopausal women OCPs – OCPs – slight increased risk of gallstone formation (which appears to be transient). Especially with high-dose estrogen (> 50 mcg) Family History and Genetics Obesity Rapid weight loss Diabetes
Elevated triglycerides Cirrhosis Gallbladder stasis (spinal cord injuries, prolonged fasting, TPN) Drugs: estrogen, OCPs, octreotide, clofibrate*, ceftriaxone** Decreased physical activity Crohn’s Disease Hemolysis
Biliary Colic Intense, dull RUQ discomfort that may radiate to the back (often right shoulder blade) lasting 30 minutes to hours. Associated Associated with nausea and vomiting. vomiting. Often post-prandial, but may be nocturnal. Not exacerbated with movement and not relieved by squatting, passing gas, or having a bowel movement. Pain is due to increased intra-gallbladder intra-gallbladder pressure that occurs when gallbladder contractions force a stone against the gallbladder outlet.
Uncomplicated Gallstone Disease
Labs should be normal!
If labs are abnormal (leukocytosis, elevated liver or pancreatic enzymes), this suggests the development of a complication (acute cholecystitis, cholangitis, cholangitis, pancreatitis). pancreatitis).
Biliary Colic Treatment…. When Stones are Present!
Pain Relief
Hydration
92% curative
Ursodiol
If severe vomiting.
Cholecystectomy
NSAIDS (or opioids)
600 mg daily Reduces need for cholecystectomy by 30%
Extracorporeal shock-wave lithotripsy therapy
Cholecystectomy Complications and Side Effects
2.6% risk of major complications in lap chole:
Bleeding, abscess formation, biliary injury, bowel injury
Diarrhea (due to lack of gallbladder)
5-12% of patients (but often improves)
Incidental Gallstones
The majority of patients with gallstones are asymptomatic.
Only 20% of patients with asymptomatic gallstones will develop symptoms over a 15-year follow up period.
References “Approach to the patient with abnormal liver biochemical and function tests.” Up To Date. 30 March 2013. “Dissolution therapy for the treatment of gallstones.” Up To Date. 30 March 2013. “Epidemiology of and risk factors for gallstones.” Up To Date. 30 March 2013. “Uncomplicated gallstone disease in adults.” Up To Date. 30 March 2013.
The Case 18 year old Hispanic female in continuity clinic with abdominal pain.
She has had intermittent abdominal pain since September, but was started on omeprazole in January for heartburn and that pain has since resolved.
This pain episode seems different from her prior episodes of pain (specifically - different location and duration).
Pain started last night after dinner and has continued on and off for the past 20 hours.
Location: RUQ, sometimes moves up and down.
7/10 pain, “squeezing”.
Worse with eating and deep breathing.
No change with activity, bowel movements, or copious amounts of pepto bismol.
Associated nausea and vomiting (NBNB).
Stooling: Usually stools daily (sometimes hard, sometimes soft), but had loose stools yesterday.
Diet: Eats a lot of fast food.
ROS Negative except for abdominal pain, diarrhea, rhinorrhea, sore throat. No fever!
PMH: PCOS, acne, obesity, heartburn
Meds: omeprazole, OCP, Retin A
NKDA
IMMS: UTD
Family Hx: no gallstones or kidney stones
Social: Lives with Mom, Mom’s fiancé, and brother. Planning on graduating high school this May and starting at a local university in the Fall.
Teen Only Interview Never been sexually active. LMP one week ago. Denies verbal, physical, sexual abuse. Denies drug use. No other concerns from patient.
Physical Exam
Completely normal vitals and exam except: Obesity Black tongue Mild RUQ tenderness to palpation
Pepto Bismol!
DDX of Acute Abdominal Pain
GI
Renal Renal stone UTI
GYN Pregnancy PID Ruptured ovarian cyst Ovarian Torsion
Appendicitis Peptic Ulcer Disease Constipation Gastroenteritis
*More specific to the RUQ* Gallstones/Biliary Colic Cholecystitis Hepatitis Pancreatitis
Follow up
Friday:
Alk phos: 112 112 (nl)
GGT 594 (abnl) (nl 21-101)
Sunday: continued pain…
Ordered hepatitis panel, CMV, EBV, total/direct bili
Ordered U/S
AST 217 (abnl) (abnl) (nl 12-32)
ALT 224 (abnl) (nl 5-32) 5-32)
Amylase 33 (nl) (nl)
Lipase 33 (nl)
Monday:
U/S: Cholelithiasis w/o evidence of cholecystitis.
No Murphy’s Sign
Risk Factors for Gallstones
4 Fs: female, > 40, fat, fertile* *Estrogen increases cholesterol secretion and progesterone reduces bile acid secretion leading to supersaturation of the bile with cholesterol which promotes stone formation. Progesterone also slows gallbladder emptying leading to bile stasis.
Risk Factors for Gallstones
Estrogen replacement therapy in post-menopausal women OCPs – OCPs – slight increased risk of gallstone formation (which appears to be transient). Especially with high-dose estrogen (> 50 mcg) Family History and Genetics Obesity Rapid weight loss Diabetes
Elevated triglycerides Cirrhosis Gallbladder stasis (spinal cord injuries, prolonged fasting, TPN) Drugs: estrogen, OCPs, octreotide, clofibrate*, ceftriaxone** Decreased physical activity Crohn’s Disease Hemolysis
Biliary Colic Intense, dull RUQ discomfort that may radiate to the back (often right shoulder blade) lasting 30 minutes to hours. Associated Associated with nausea and vomiting. vomiting. Often post-prandial, but may be nocturnal. Not exacerbated with movement and not relieved by squatting, passing gas, or having a bowel movement. Pain is due to increased intra-gallbladder intra-gallbladder pressure that occurs when gallbladder contractions force a stone against the gallbladder outlet.
Uncomplicated Gallstone Disease
Labs should be normal!
If labs are abnormal (leukocytosis, elevated liver or pancreatic enzymes), this suggests the development of a complication (acute cholecystitis, cholangitis, cholangitis, pancreatitis). pancreatitis).
Biliary Colic Treatment…. When Stones are Present!
Pain Relief
Hydration
92% curative
Ursodiol
If severe vomiting.
Cholecystectomy
NSAIDS (or opioids)
600 mg daily Reduces need for cholecystectomy by 30%
Extracorporeal shock-wave lithotripsy therapy
Cholecystectomy Complications and Side Effects
2.6% risk of major complications in lap chole:
Bleeding, abscess formation, biliary injury, bowel injury
Diarrhea (due to lack of gallbladder)
5-12% of patients (but often improves)
Incidental Gallstones
The majority of patients with gallstones are asymptomatic.
Only 20% of patients with asymptomatic gallstones will develop symptoms over a 15-year follow up period.
References “Approach to the patient with abnormal liver biochemical and function tests.” Up To Date. 30 March 2013. “Dissolution therapy for the treatment of gallstones.” Up To Date. 30 March 2013. “Epidemiology of and risk factors for gallstones.” Up To Date. 30 March 2013. “Uncomplicated gallstone disease in adults.” Up To Date. 30 March 2013.
