Biliary colic

and Sabine Schrör, medical journalist

Hanna Rutkowski is a freelance writer for the medical team.

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Sabine Schrör is a freelance writer for the medical team. She studied business administration and public relations in Cologne. As a freelance editor, she has been at home in a wide variety of industries for more than 15 years. Health is one of her favorite subjects.

More about the experts All content is checked by medical journalists.

Spasmodic, violent pain in the upper abdomen is typical of biliary colic. The complaints can radiate to the shoulder and back and last between a few minutes and several hours. They are usually caused by gallstones or an inflamed gallbladder. Women are affected much more often than men. Read everything you need to know about the symptoms, causes and treatment options for biliary colic.

Brief overview

• What is biliary colic? Biliary colic is cramp-like, violent pain in the right upper abdomen, which typically radiates over a large area, particularly to the stomach, back and shoulder. They can last a few minutes or several hours. Common accompanying symptoms are nausea and vomiting.

• What causes biliary colic? Biliary colic is usually caused by gallstones. These clog and irritate the bile ducts. As a result, the gallbladder can become inflamed. Women are affected more often than men. A high-fat diet and obesity favor gallstones and, as a result, biliary colic.

• What happens with untreated biliary colic? If you do not have biliary colic cleared up, there is a risk of serious complications: the bile duct and gall bladder can become extensively inflamed. In severe cases, your gallbladder can “rupture”. On the other hand, a tumor of the biliary tract can develop on the basis of chronic inflammation.

• Do I have to see a doctor if I have biliary colic? Be sure to consult a doctor if you suffer from biliary colic symptoms. Long-term colic, in particular, indicates severe gallstone disease.

• How is biliary colic diagnosed? If you have biliary colic, the doctor will examine your abdomen and draw blood. With the help of an ultrasound device, he can usually recognize gallstones, inflammation and malignant changes in the gallbladder. A mirroring of the gallbladder and ducts may also be necessary - it is often a diagnosis and therapy at the same time.

• What helps with biliary colic? Acute biliary colic pain is treated with pain relievers (e.g. metamizole, ibuprofen, paracetamol) and with anticonvulsant medication. A special X-ray examination, endoscopic retrograde cholanigiopancreatography (ERCP), is also used to remove smaller gallstones. In the medium term, surgical removal of the gallbladder (cholecystectomy) is the therapy of first choice in order to avoid complications.

• How can I prevent biliary colic? Ultimately, biliary colic can only be avoided by preventing the formation of gallstones. So make sure you have a balanced diet, drink enough and try to avoid or reduce excess weight.

Biliary colic: description

Biliary colic originates from the gall bladder (Vesica biliaris). This small hollow body lies in a protected pit below the liver. It stores and thickens the bile produced by the liver. From the gallbladder, the bile (bile for short) reaches the duodenum via the bile duct (ductus choledochus), where it is mainly needed for fat digestion.

If the gallbladder becomes inflamed or gallstones have formed, biliary colic can occur: the gallbladder spasms, which is accompanied by severe, wave-like pain. The symptoms usually appear in spurts, so they lessen a little in the meantime and then strike again with full force.

The most common cause of biliary colic is gallstones. Women are affected much more often: around one in five women, but only one in ten men, has gallstones. But not all gallstone carriers get biliary colic - only about 25 percent are affected.

Biliary colic: key symptoms

Biliary colic can last anywhere from 15 minutes to five hours. The pain usually increases over time and radiates from the upper abdomen to the back and right shoulder.

Key symptoms of biliary colic

• sudden violent cramping pain in the upper abdomen

• nausea
• Vomit
• Jaundice (jaundice)
• Fever with chills
• Light-colored (discolored) stool due to a lack of bile pigments (if the bile duct is blocked by a gallstone, for example) or fatty stool (due to impaired fat breakdown)
• dark urine

Biliary colic: causes

The main cause of biliary colic are gallstones that block the bile duct. Around 15 percent of the population have these stony companions, but only a quarter of them lead to the typical complaints.

Gallstones (cholelithiasis)

In addition to liquid, bile also contains substances such as cholesterol, bile salts, the bile pigment bilirubin and lecithin. If their ratio changes, solids can precipitate, solidify and gallstones can form. This can happen, for example, with a high-fat diet: the proportion of cholesterol then increases, which can subsequently be deposited as a cholesterol stone in the gallbladder. There are also so-called bilirubin stones, which arise when the ratio between bile salts and the bile pigment bilirubin changes.

Depending on where the gallstone is located, a distinction is made between bile duct stones (choledocholithiasis) and gallbladder stones (cholecystolithiasis).

The gallstones often only cause discomfort when they are flushed into the narrow bile duct (common bile duct) together with the bile and clog or constrict it. Then the gallbladder contracts repeatedly in a convulsive manner in order to carry the offending stones further into the small intestine. In addition, the rough stones irritate the wall of the bile duct, which can still cause mild discomfort days after the colic. However, the colic itself suddenly disappears as soon as the gallstone has passed out of the duct and into the small intestine.

But the gallstones, which seem to lie quietly and unnoticed in the gallbladder, can also cause problems over time. Because they can trigger gallbladder inflammation (cholescystitis).

Risk factors for gallstones

There are a few risk factors that can make gallstones develop. They are referred to as "the five F's":

• Female: Women are affected twice as often as men.
• Fertile: The female hormone estrogen probably plays a role in the formation of gallstones. This is supported by the fact that gallstones occur more frequently during pregnancy and when using drugs containing estrogen (pill, hormone therapy).
• Fat: Obese people are at higher risk for gallstones.
• Forty: Gallstone complaints are mostly seen in people over 40 years of age.
• Fair: Light-skinned people are more likely to suffer from gallstones than dark-skinned people.

Complications and possible secondary diseases

Up to a third of all biliary colic patients develop complications or other diseases, for example:

• Breakthrough of the gallbladder: When a gallstone blocks the bile duct, the bile builds up in the gallbladder. As a result, the gallbladder can burst (gallbladder perforation), causing bile to escape into the abdomen. This can lead to life-threatening inflammation of the peritoneum (peritonitis), which is why the gallbladder must be surgically removed as soon as possible. In addition to biliary colic, typical symptoms of gallbladder perforation are nausea and vomiting.
• Inflammation of the bile duct: In acute cholangitis, the bile duct blocked by gallstones is inflamed with pus. Three symptoms (Charcot's triad II) are characteristic of acute cholangitis: jaundice (jaundice), fever and severe epigastric pain.
• Gallbladder Inflammation: Gallstones are rough. Friction can irritate the gallbladder wall so badly that it becomes inflamed (cholecystitis). If this happens suddenly, fever, colicky pain in the upper abdomen and high levels of inflammation in the blood are typical. The gallbladder can also be suppurated as a result of a bacterial infection (gallbladder empyema). This chronic form of gallbladder inflammation can develop into gallbladder cancer.
• Enlargement of the gallbladder: If the bile fluid builds up in the bile duct, the gallbladder can enlarge palpably. Doctors speak of gallbladder hydrops. If left untreated, it can develop into inflammation.
• Gallbladder cancer: Chronic inflammation of the gallbladder (cholecystitis) and gallstones increase the risk of gallbladder cancer (gallbladder cancer). However, this usually only develops in old age. Symptoms include loss of appetite, unwanted weight loss, jaundice (jaundice), nausea and vomiting, and biliary colic.

Biliary colic: when do you need to see a doctor?

You should always have a doctor clear up severe, suddenly onset upper abdominal pain as quickly as possible. Because there could be gallstones behind it. And these don't always come off by themselves. Sometimes they block the bile duct permanently, which can lead to serious complications. In the worst case, the bile can burst due to the accumulated bile fluid (gallbladder rupture). In addition, gallstones can block the adjacent duct of the pancreas and thus cause a potentially dangerous pancreatitis.

Be sure to see a doctor if you notice typical symptoms of biliary colic: upper abdominal pain, nausea, vomiting, jaundice (jaundice), fever with chills, fatty stools or pale (discolored) stools, dark urine.

Biliary colic: what does the doctor do?

Biliary colic is usually associated with symptoms that are so typical that a doctor will usually recognize it immediately. Nevertheless, you should describe your symptoms to the doctor as precisely as possible. As part of this initial consultation to collect your medical history (anamnesis), the doctor will ask, for example, since when and where exactly you have been in pain and how it is expressed. He also asks about digestive disorders, because diseases of the gallbladder always affect fat digestion and bowel movements (e.g. light-colored stools due to a lack of bile pigments). The urine, on the other hand, is usually darker than usual.

Physical examination

During the physical exam, the doctor will palpate your stomach. He can determine whether the spleen and liver are enlarged and whether the stomach is hard or soft. Two special examination methods are particularly meaningful for the doctor:

• Murphy's Sign: The doctor asks the patient to take a deep breath while pressing their fingers under the right costal arch. If this hurts, the patient suddenly stops taking a deep breath. This indicates a gallstone disease (cholelithiasis) or an inflammation of the bile ducts (cholecystitis).
• Courvoisier's sign: The examination is exactly the same as for Murphy's sign, but does not cause pain in the patient. However, the doctor finds that the gallbladder is bulging - an indication that the bile duct is blocked by a tumor or scarring.

Blood test

The doctor will also draw blood from you to have specific liver, bile and pancreatic tests performed. These include, for example:

• Alkaline phosphatase (AP): If this value is increased, this, together with other liver values, indicates diseases of the liver or the bones.
• Gamma-GT: This value is increased especially in the case of disturbances of the biliary outflow of the liver.
• GPT (ALT): This enzyme is only found in the liver and is increased when damaged.
• Bilirubin: The bile pigment accumulates in the blood due to a disturbance in the drainage of the bile.
• Lipase: If this value is increased, this can indicate inflammation of the pancreas.

Other research methods

An ultrasound examination of the abdomen (abdominal ultrasound) is the method of choice to get to the bottom of biliary colic. Not only can gallstones be recognized with this, but also changes in the gallbladder such as tumors, polyps or inflammations. Together with the physical examination and a positive Murphy sign, for example, the doctor can usually determine very precisely whether the gallbladder is inflamed or whether there are gallstones.

Endoscopic retrograde cholanigiopancreatography (ERCP) enables diagnosis and therapy at the same time. The doctor leads a thin tube with a small camera at the front end (endoscope) over the mouth and into the duodenum, where the bile duct system joins (usually together with the pancreatic duct). Now he injects an x-ray contrast agent into the duct system. Then this trunk area is x-rayed. Pathological changes such as a narrowing of the biliary tract caused by a gallstone can be clearly seen on the X-ray. The doctor can then immediately insert fine medical instruments through the tubular endoscope to remove the gallstone.

treatment

If there is an acute biliary colic caused by gallstones, the doctor will first administer anticonvulsants (antispasmodics) and strong pain relievers. As part of the more detailed search for the cause by means of ERCP - as mentioned above - a causal treatment can often already be carried out (e.g. removal of a gallstone, widening of a bile duct narrowing with the help of a tube = stent).

Smaller gallstones in the gallbladder or bile ducts can sometimes be dissolved with medication (with ursodeoxycholic acid = UDCA). In most cases, however, a complete removal of the gallbladder (cholecystectomy) is necessary in order to avoid serious complications. Today, the procedure is mainly performed laparoscopically: The medical instruments required are introduced through small abdominal incisions. In contrast, a large abdominal incision is rarely necessary to remove the gallbladder.

Biliary colic: you can do it yourself

In order to bridge the time until the doctor's visit, the symptoms of acute biliary colic can often be alleviated with the following tips:

• Hot water bottle: A hot water bottle on the stomach is the easiest and fastest way to alleviate the severe pain. The warmth can loosen the cramped muscles.
• Hot wraps: A belly wrap with cotton towels soaked in hot water also relaxes the aching stomach.
• Avoid food and sugary drinks: During biliary colic, you should neither eat nor drink high-calorie drinks such as lemonade or juices. This will prevent the gallbladder from spilling bile, which would cause even more pain.

Biliary colic: how to prevent it

Ultimately, the only way to avoid painful, extremely uncomfortable biliary colic is to prevent the formation of gallstones:

• Low-fat diet: Make sure you have a balanced, high-fiber and low-fat diet. For example, avoid heavy sauces and fried foods and consume fresh fruits and vegetables regularly.
• Avoiding obesity: With a healthy, balanced diet and sufficient exercise, you can reduce or prevent obesity.
• Drink a lot: Make sure you drink enough. A lack of fluids promotes the formation of gall and kidney stones and thus promotes the development of biliary colic.

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