Pain
- epigastric or RUQ pain
- constant (not colic/waxing and waning)
- starts suddenly, max. intensify in 60 min, resolves gradually over 6h. (Lasts 30min -6h)
- frequently happen at night or after fatty meal, relieved by morphine
- can radiate to back/scapula/right shoulder
- nausea/vomiting
- rolling about
- no systemic signs -eg. fever , chills
Pathophysiology
- The visceral pain is caused by impaction of gallstone in the cystic duct
- This distention of cystic duct activates visceral afferent sensory neurons.
- The resultant pain is poorly localized in dermatomes T8/9 (mid epigastrium, RUQ) although it may radiate to RUQ.
- Pain is relieved when the gallstone migrates back into GB, passes through the ampulla, or falls back into CBD.
Differential Diagnosis
Pancreatitis, PUD, hiatus hernia, gastritis, IBS, angina pectoris
Investigation
- In uncomplicated biliary colic,FBC, LFT(AST, ALT, Alk Phos) & amylase are normal
- US- sensitive(95%) - gallstones within GB with mild wall oedema
- Hepatobiliary scintigraph / HIDA scan- (if diagnosis is uncertain after US) – add cholecystokinin (CCK) and morphine to increase sensitivity
- ERCP - for unresolved biliary colic symptoms after cholecystectomy. Can perform sphincterotomy in type I and II Sphincter of Oddi Dysfunction (SOD)
- AXR – exclude eg. bowel obstruction, perforation
Management
- Pain – Meperidine (pethidine) IM.1mg/kg every 3h. Morphine is avoided
- Nausea/vomiting - antiemetic eg. metoclopramide IV
- Uncomplited biliary colic resolves with conservative treatment.
- Elective cholecystectomy (95% success)
- Diet – after attack, avoid high fat meals., lose weight
- Bed rest
2 comments:
The severe visceral pain radiates almost everywhere, not necessarily at the RHC. The location of the gallbladder may also be variable. We have a patient being treated for years for "chronic gastritis" when an US finally reveals multiple calculi. She was cured by Cholecystectomy.Cholecystectomy now performed in HUSM laparascopically which reduces hospital stay. During Abah's time any patient with the the "5 Fs" are looked with high suspicion for gallbladder stones... Fat, Female, Forty, Fair, Flatulent. Conclusion: Every casualty setting must have an US Scanner with FAST calibration for quick diagnoses...like at Dr Kupe's Clinic...
Ok, thanks abah for the real life Kelantanese clinical scenario. I'll remember the 5F's: female, fat, fertile, forties, fair. I've put that in another entry.
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