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Referral and warning signs
When to refer
Refer to surgeon for elective cholecystectomy if patient experiences biliary colic. Urgent referral needed if complications suspected (Acute Cholecystitis, Cholangitis, Gallstone Pancreatitis).
Red flags
- Persistent RUQ/epigastric pain (>6 hours)
- Fever, chills
- Jaundice
- Positive Murphy's sign (inspiratory arrest on RUQ palpation)
- Signs suggesting pancreatitis
Signs and symptoms
- Asymptomatic (most common - discovered incidentally).
- Biliary Colic:
- - Severe, constant, aching pain in the epigastrium or Right Upper Quadrant (RUQ).
- - Pain often radiates to the right shoulder blade or back.
- - Rapid onset, lasts 30 minutes to several hours, then resolves completely.
- - Often precipitated by fatty meals.
- - May be associated with nausea and vomiting.
- - Absence of fever, persistent tenderness, or jaundice differentiates from cholecystitis/cholangitis.
Risk factors
- Female gender ('Female, Fertile, Forty, Fat' - classic mnemonic, but occurs outside this)
- Increasing age (>40)
- Obesity
- Rapid weight loss / Bariatric surgery
- Pregnancy / Multiparity
- Oral contraceptives / Oestrogen therapy
- Family history
- Certain ethnicities (e.g., Native Americans, Hispanics)
- Diabetes mellitus
- Dyslipidemia
- Crohn's disease / Ileal resection (affecting bile salt resorption)
- Cirrhosis
- Haemolytic anaemias (pigment stones)
Diagnosis
Clinical assessment
Suspect biliary colic based on characteristic episodic RUQ/epigastric pain, often post-prandial. Asymptomatic stones often incidental finding. Differentiate colic from cholecystitis (persistent pain, fever, Murphy's sign), cholangitis (fever, RUQ pain, jaundice - Charcot's triad), pancreatitis, PUD, GERD, MI.
Investigations
- Abdominal Ultrasound: Investigation of choice. Highly sensitive and specific for detecting gallstones within the gallbladder.
- Liver Function Tests (LFTs): Usually normal in asymptomatic cholelithiasis and uncomplicated biliary colic. May be transiently elevated if stone passes through CBD.
- Amylase/Lipase: Rule out gallstone pancreatitis.
- CBC: Usually normal.
Diagnostic criteria
Presence of gallstones on ultrasound. Biliary colic diagnosed clinically based on characteristic pain pattern in a patient with known gallstones.
Management
Non-pharmacological management
- Asymptomatic Gallstones: Generally no treatment required ('masterly inactivity'). Cholecystectomy may be considered in specific high-risk groups (e.g., transplant candidates, porcelain gallbladder - controversial).
- Biliary Colic (Acute Episode):
- - Analgesia: NSAIDs (e.g., Diclofenac IM/PO, Ketorolac IV/IM) are very effective. Opioids (Pethidine, Morphine) if NSAIDs contraindicated/insufficient.
- - Antispasmodics (e.g., Hyoscine butylbromide) may provide some relief.
- Lifestyle/Diet: Low-fat diet may help reduce frequency of colic episodes while awaiting surgery.
Pharmacological treatment
- Analgesia for acute colic (see above).
- Ursodeoxycholic Acid (UDCA): Oral bile acid therapy can dissolve small, cholesterol-rich gallstones over months/years. Limited efficacy, high recurrence rate after stopping. Rarely used, mainly for patients unfit for surgery.
- Elective Cholecystectomy (Surgical removal of the gallbladder): Definitive treatment for symptomatic gallstones (biliary colic, cholecystitis history) to prevent recurrence and complications. Usually performed laparoscopically.
Monitoring
- Monitor frequency and severity of biliary colic episodes.
- Monitor for development of complications (cholecystitis, cholangitis, pancreatitis).
Complications
- (Related to gallstones themselves):
- Acute Cholecystitis
- Choledocholithiasis (stones in common bile duct) -> Obstructive Jaundice, Cholangitis, Gallstone Pancreatitis
- Gallstone Pancreatitis
- Gallstone Ileus (rare - stone erodes into bowel causing obstruction)
- Mirizzi Syndrome (stone impacted in cystic duct compresses common hepatic duct)
- Gallbladder Cancer (rare, associated with chronic inflammation/large stones/porcelain gallbladder)
Prevention
- Maintain healthy weight.
- Avoid rapid weight loss.
- Healthy diet (lower fat, higher fibre may help).
- UDCA prophylaxis during rapid weight loss (e.g., post-bariatric surgery) may reduce stone formation.
Patient education
- Explain gallstones and biliary colic.
- Dietary advice (low fat may reduce attacks).
- Pain management for colic episodes.
- Rationale for cholecystectomy if symptomatic.
- Signs of complications (fever, persistent pain, jaundice) requiring urgent medical attention.
Uganda-specific notes
Prevalence may be lower than Western countries but increasing with dietary changes/obesity. Ultrasound is key diagnostic tool. Access to laparoscopic cholecystectomy limited; open surgery more common where available. Complications like cholangitis/pancreatitis require urgent referral.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 6, Section 6.5.8