Overview
Definition:
Biliary colic is characterized by episodic, severe, and often colicky pain in the right upper quadrant (RUQ) or epigastric region, typically caused by transient obstruction of the cystic duct or common bile duct by gallstones (cholelithiasis)
While historically considered an adult condition, its incidence is rising in adolescents, necessitating increased awareness and specific management strategies.
Epidemiology:
The prevalence of gallstones in children and adolescents is increasing, with estimates varying from 0.3% to over 10% in some pediatric populations, particularly those with risk factors
Adolescents are more commonly affected than younger children
Risk factors include obesity, rapid weight loss, certain medications (e.g., ceftriaxone, oral contraceptives), genetic predisposition, hemolytic anemias, and total parenteral nutrition (TPN).
Clinical Significance:
Recognizing and managing biliary colic and cholelithiasis in adolescents is crucial due to the potential for complications such as cholecystitis, cholangitis, pancreatitis, and even long-term sequelae
Prompt diagnosis and appropriate referral for surgical evaluation are vital to prevent morbidity and ensure favorable outcomes in this growing demographic.
Clinical Presentation
Symptoms:
Abrupt onset of severe, steady or colicky pain in the RUQ or epigastrium
Pain often radiates to the right shoulder or scapula
Nausea and vomiting are common
Symptoms are typically postprandial, especially after fatty meals
Episodes usually last 15-60 minutes but can persist for hours
Intermittent jaundice is possible with common bile duct stones.
Signs:
Tenderness in the RUQ or epigastrium
Murphy's sign may be positive in cases of acute cholecystitis
Abdominal distension, guarding, and rebound tenderness can be present if inflammation is severe
Fever may indicate associated infection
Icterus suggests biliary obstruction.
Diagnostic Criteria:
No strict formal diagnostic criteria exist for biliary colic
Diagnosis is primarily clinical, supported by imaging
The presence of gallstones on ultrasound in a patient with characteristic pain strongly supports the diagnosis of symptomatic cholelithiasis and biliary colic
Criteria for acute cholecystitis include RUQ pain, fever, leukocytosis, and ultrasound findings (gallbladder wall thickening, pericholecystic fluid, sonographic Murphy's sign).
Diagnostic Approach
History Taking:
Detailed history of pain characteristics (onset, duration, location, radiation, quality, aggravating/alleviating factors)
Ask about recent fatty meals
Inquire about weight loss history, family history of gallstones, and use of medications known to induce gallstones
Screen for hemolytic disorders or conditions requiring TPN
Identify any prior episodes or abdominal surgeries.
Physical Examination:
Perform a thorough abdominal examination, palpating for tenderness, masses, and organomegaly
Assess for guarding, rebound tenderness, and Murphy's sign
Evaluate for signs of jaundice (scleral icterus) and ascites
Check for signs of systemic illness such as fever.
Investigations:
Abdominal Ultrasound: The gold standard for detecting gallstones, assessing gallbladder wall thickness, and identifying sludge
It can also visualize common bile duct dilation
Complete Blood Count (CBC): May show leukocytosis in acute cholecystitis
Liver Function Tests (LFTs): Elevated bilirubin and alkaline phosphatase suggest biliary obstruction
Amylase and Lipase: To rule out pancreatitis
Hepatobiliary Iminodiacetic Acid (HIDA) Scan: Useful if ultrasound is inconclusive for acute cholecystitis or to assess cystic duct patency
Magnetic Resonance Cholangiopancreatography (MRCP): For detailed visualization of the biliary tree and pancreatic duct, especially if common bile duct stones are suspected.
Differential Diagnosis:
Peptic ulcer disease, gastroesophageal reflux disease (GERD), appendicitis (especially if pain is atypical or refers), pancreatitis, hepatitis, renal colic, functional abdominal pain, Meckel's diverticulitis, mesenteric adenitis, pneumonia (referred pain), and musculoskeletal pain.
Management
Initial Management:
Pain control with analgesics (e.g., NSAIDs like ketorolac, or opioids if severe)
Antiemetics for nausea/vomiting
NPO status if significant pain or suspicion of acute cholecystitis
Intravenous fluids for hydration
Close monitoring for signs of complications.
Medical Management:
Primarily symptomatic relief of pain
Ursodeoxycholic acid (UDCA) may be considered for select cases of cholesterol gallstones, though efficacy and indications in adolescents are less established than in adults and typically reserved for specific situations or non-surgical candidates
Antibiotics (e.g., ceftriaxone) are indicated if acute cholecystitis or cholangitis is suspected or confirmed.
Surgical Management:
Laparoscopic cholecystectomy is the definitive treatment for symptomatic cholelithiasis and is indicated for recurrent biliary colic and acute cholecystitis
Early surgical intervention is generally preferred in adolescents to prevent complications
For suspected common bile duct stones (choledocholithiasis), preoperative MRCP and potential endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy may be required before cholecystectomy
Open cholecystectomy may be necessary in cases of severe inflammation, adhesions, or unexpected intraoperative findings.
Supportive Care:
Adequate hydration, electrolyte balance, and nutritional support
Regular monitoring of vital signs, pain levels, and laboratory parameters
Post-operative care focuses on pain management, early mobilization, and wound care
Dietary modifications (low-fat diet) may be advised temporarily post-operatively.
Complications
Early Complications:
Acute cholecystitis: Inflammation of the gallbladder, often due to sustained cystic duct obstruction
Cholangitis: Infection of the biliary tree, presenting with Charcot's triad (RUQ pain, jaundice, fever)
Ascending cholangitis can lead to sepsis and is a surgical emergency
Gallstone pancreatitis: Inflammation of the pancreas caused by a gallstone obstructing the pancreatic duct
Perforation of the gallbladder or bile duct
Biliary peritonitis.
Late Complications:
Post-cholecystectomy syndrome (though rare in adolescents)
Recurrence of gallstones if only partial treatment or if other underlying conditions persist
Chronic cholecystitis with progressive gallbladder damage
Strictures of the biliary tree
Cholangiocarcinoma (very rare in this age group).
Prevention Strategies:
For patients at risk (obese, rapid weight loss, TPN), strategies include gradual weight loss, dietary modifications, and consideration of UDCA in specific cases
For those diagnosed with gallstones, prompt surgical management after symptomatic episodes or acute cholecystitis is the best prevention against further complications.
Prognosis
Factors Affecting Prognosis:
Prompt diagnosis and treatment, absence of complications (like cholangitis or pancreatitis), and the patient's overall health status significantly impact prognosis
Adolescents generally have a good prognosis with timely cholecystectomy.
Outcomes:
Most adolescents with symptomatic cholelithiasis and those who undergo cholecystectomy have excellent outcomes and resolution of symptoms
Recurrence of symptoms post-cholecystectomy is uncommon.
Follow Up:
Routine follow-up after cholecystectomy is generally not required unless complications arise
Patients should be advised to report any new or persistent abdominal symptoms
Long-term monitoring may be indicated for those with underlying conditions that predispose them to gallstone formation.
Key Points
Exam Focus:
Increased incidence of gallstones in adolescents
risk factors (obesity, rapid weight loss)
Ultrasound is the primary diagnostic tool
Laparoscopic cholecystectomy is the definitive management
Recognize complications like acute cholecystitis, cholangitis, and pancreatitis.
Clinical Pearls:
Always consider biliary causes for RUQ or epigastric pain in adolescents, especially if postprandial or associated with fatty meals
Don't underestimate gallstones in this age group
Early surgical referral is key to prevent serious complications.
Common Mistakes:
Attributing all upper abdominal pain in adolescents to functional causes without thorough investigation
Delaying surgical referral when symptoms are recurrent or suggestive of cholecystitis
Misinterpreting ultrasound findings or not considering common bile duct involvement.