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Bikiary colic

1. Clinical differentiation between
biliary colic and acute
cholecystitis
Prof. tharwat I Sulaiman
College of medicine
Baghdad Univerisity

2. Biliary clolic
•biliary colic occurs when
gallstones or sludge impact in
the cystic duct during a
gallbladder contraction,
increasing the gallbladder
wall tension.
• In most cases, the pain
resolves over 30 to 90
minutes as the gallbladder
relaxes and the obstruction is
relieved.

3. Biliary colic
•lasts 1-5 hours of constant pain
•in the epigastrium or right upper quadrant.
•The pain is severe, dull or boring, constant (not colicky), and may
radiate to the right scapular region or back (Collin’s sign).
• Patients tend to move around to seek relief from the pain.
•pain develops hours after a meal, occurs frequently at night.
Associated symptoms include nausea, vomiting, pleuritic pain,
and fever.

4. biliary colic
•the pain increases steadily over about 10 to 20 minutes and then
gradually wanes when the gallbladder stops contracting and the stone
falls back into the gallbladder.
•The pain is constant in nature and is not relieved by emesis, antacids,
defecation, flatus, or positional changes. It may be accompanied by
diaphoresis, nausea, and vomiting.

5. •Other symptoms, often associated with cholelithiasis, include
indigestion, dyspepsia, belching, bloating, and fat intolerance.
However, these are very nonspecific

6. Biliary colic
•Physical Examination
•1. the pain is poorly localized and visceral in origin
•2.the patient has an essentially benign abdominal examination
without rebound or guarding.
•3.Fever is absent.
•Although voluntary guarding may be present, no peritoneal signs are
present. Tachycardia and diaphoresis may be present as a
consequence of pain. These should resolve with appropriate pain
management

8. Biliary colic Vs acute cholecystitis

9. Acute cholecystitis
•Persistence of cystic duct obstruction
• inflammation of the gallbladder
•peritoneal irritation
•a well-localized pain in the right
upper quadrant,
•rebound tenderness and guarding.
•positive Murphy sign.
•Fever

10. Acute cholecystitis
•Persistence of biliary obstruction leads to cholecystitis and
persistent right upper quadrant pain.
•The character of the pain is similar to gallbladder colic, but more
prolonged >3 hours
•Nausea, vomiting, and low-grade fever.
•similar previous episodes in the past.
•Patients with cholecystitis are usually more ill appearing than
simple biliary colic patients, and they usually lie still on the
examination table, as any movement may aggravate any
peritoneal signs

11. U/S of the abdomen showing thick wall edematous gall
bladder (acute cholecystitis

12. Edematous gall bladder wall

13. Acute cholecystitis

•The presence of fever, persistent tachycardia, hypotension, or
jaundice necessitate a search for complications of cholelithiasis,
including cholecystitis, cholangitis, pancreatitis, or other systemic
causes

14. Laboratory tests
•An elevated WBC is expected but not reliable. 61% of patients with
cholecystitis had a WBC count greater than 11,000 cells/µL.
•A WBC greater than 15,000 cells/µL may indicate perforation or
gangrene.

15. Imaging studies
•Ultrasonography and nuclear medicine studies are the best imaging
•studies for the diagnosis of both cholecystitis and cholelithiasis
•Diffusion-weighted (DW) magnetic resonance imaging (MRI) shows
potential for differentiating between acute and chronic cholecystits.
•Plain radiography,
• computed tomography (CT) scans,
• and endoscopic retrograde cholangiopancreatography (ERCP) are
diagnostic adjuncts.

16. U/S in biliary colic
Thin wall gall bladder
Multiple gall stones
Acoustic shadow

17. General ultrasonographic features
in acute cholecystitis
•Findings include gallstones or sludge and one or more of the
following conditions:
•Gallbladder wall thickening (>2-4 mm) - False-positive wall thickening
found in hypoalbuminemia, ascites, congestive heart failure, and
carcinoma
•Gallbladder distention (diameter >4 cm, length >10 cm)
•Pericholecystic fluid from perforation or exudate - May be seen as a
hypoechoic or anechoic region seen along the anterior surface of the
gallbladder within the hepatic parenchyma
•Air in the gallbladder wall (indicating gangrenous cholecystitis)
•Ultrasonographic Murphy sign (86-92% sensitive, 35% specific) - pain
when the probe is pushed directly on the gallbladder (not related to
breathing)