What is the treatment for a patient presenting with biliary colic?

Treatment for Biliary Colic

For acute biliary colic, administer intramuscular NSAIDs (diclofenac 75 mg or ketorolac 60 mg) as first-line treatment, followed by laparoscopic cholecystectomy within 7-10 days to prevent recurrence and complications. 1

Immediate Pain Management

First-Line Analgesic Treatment

• Administer intramuscular diclofenac 75 mg as the preferred initial treatment for acute biliary colic when diagnosis is clear and no complications are present 2, 3
• Alternatively, use intramuscular ketorolac 60 mg, which provides equivalent pain relief to opioids without the side effects 4
• NSAIDs provide complete pain relief in approximately 78% of patients (21/27) compared to only 27% (7/26) with placebo 3
• NSAIDs are superior to spasmolytics for pain control (RR 1.47,95% CI 1.03-2.10) and equivalent to opioids (RR 1.05,95% CI 0.82-1.33) 5

Additional Benefits of NSAIDs Beyond Pain Control

• NSAIDs significantly reduce progression to acute cholecystitis: only 15% (4/27) of diclofenac-treated patients developed cholecystitis versus 42% (11/26) of placebo patients 3
• Overall complication rate is reduced by 47% with NSAIDs compared to placebo (RR 0.53,95% CI 0.31-0.89) 5
• Intravenous tenoxicam and injectable flurbiprofen are equally effective alternatives when diclofenac or ketorolac are unavailable 6

When to Admit

• If severe pain does not remit within 1 hour of NSAID administration, admit the patient to hospital 2
• Immediate admission is indicated for signs of complications including fever, persistent vomiting, jaundice, or peritoneal signs 2

Definitive Treatment: Laparoscopic Cholecystectomy

Timing of Surgery

• Perform laparoscopic cholecystectomy within 7-10 days of symptom onset for uncomplicated biliary colic 2, 1
• Early cholecystectomy (within 7-10 days) significantly reduces mortality compared to expectant management (7.9% vs 14.1%) 1
• Early surgery also decreases recurrent pain episodes, jaundice, and cholangitis 1

Surgical Approach

• Laparoscopic cholecystectomy is the definitive treatment for symptomatic cholelithiasis 1
• Use single-shot antibiotic prophylaxis if early intervention is performed; no postoperative antibiotics are needed for uncomplicated cases 2
• Open cholecystectomy serves as an alternative when laparoscopic approach is not feasible 2

Important Caveat

• Approximately 30% of patients may not experience recurrent episodes without surgery, but this unpredictability supports proceeding with definitive intervention 1
• Do not delay cholecystectomy beyond 4 weeks, as this increases risk of recurrent attacks 1

Management of Common Bile Duct Stones

When ERCP is Required

• Perform ERCP with sphincterotomy and stone extraction within 72 hours for patients with biliary obstruction or cholangitis 2, 1
• For septic shock or clinical deterioration despite antibiotics, perform urgent ERCP within 24 hours 1
• ERCP with biliary sphincterotomy and endoscopic stone extraction is the primary treatment for post-cholecystectomy common bile duct stones 2

Imaging Before ERCP

• Obtain MRCP in patients with suspected common bile duct stones before proceeding to ERCP 2
• Ultrasound is the investigation of choice for suspected acute cholecystitis 2
• CT with IV contrast is appropriate when ultrasound is inconclusive 2

Management of Complications

Acute Cholangitis Recognition and Treatment

• Initiate broad-spectrum antibiotics immediately upon recognition of cholangitis (fever, jaundice, abdominal pain with biliary obstruction) 2, 1
• For patients with sepsis, start appropriate antibiotics within 1 hour of diagnosis 2
• For less severe cases, administer antibiotics within 6 hours of diagnosis 2

Antibiotic Selection Based on Severity

For severe infections with septic shock: 1

• Piperacillin/tazobactam 6 g/0.75 g loading dose, then 4 g/0.5 g every 6 hours or 16 g/2 g by continuous infusion 2
• Alternative: meropenem 1 g every 6 hours by extended infusion 2
• Alternative: imipenem/cilastatin 500 mg every 6 hours by extended infusion 2
• Alternative for beta-lactam allergy: aztreonam combined with amikacin 1

For mild-moderate cases in immunocompetent patients: 2, 1

• Amoxicillin/clavulanate 2 g/0.2 g every 8 hours (preferred due to oral administration capability)
• For beta-lactam allergy: eravacycline 1 mg/kg every 12 hours or tigecycline 100 mg loading dose then 50 mg every 12 hours 2

Duration of Antibiotic Therapy

• Continue antibiotics for 2-4 days in immunocompetent, non-critically ill patients if source control is adequate 2
• Extend to up to 7 days based on clinical conditions and inflammation indices in immunocompromised or critically ill patients 2
• Patients with ongoing signs of infection beyond 7 days warrant diagnostic investigation 2

Biliary Drainage Procedures

Endoscopic Approach (First-Line)

• Endoscopic internal biliary catheter with removable plastic stent is the preferred initial approach for biliary obstruction 1
• ERCP is the safest and most effective method compared to percutaneous or surgical drainage 2
• ERCP-related pancreatitis occurs in approximately 3.5% of cases (range 1.6%-15.7%) 2
• Post-ERCP cholangitis occurs in less than 1% of procedures 2

Percutaneous Approach (Second-Line)

• Percutaneous internal/external biliary catheter is appropriate for hilar obstruction from malignancy or when endoscopic access fails 1
• Percutaneous transhepatic biliary drain (PTBD) is reserved for patients who have failed ERCP or have difficult anatomy 2

Critical Stent Management

• Remove biliary stents within 1-2 weeks to prevent complications; longer duration significantly increases risk 1

High-Risk and Special Populations

Patients Unfit for Surgery

• Percutaneous cholecystostomy is an option for acute cholecystitis in patients with multiple comorbidities who cannot tolerate surgery 2, 1
• Cholecystostomy is inferior to cholecystectomy in terms of major complications for critically ill patients 2
• Continue antibiotic therapy for 4 days after cholecystostomy placement 2
• For prohibitive surgical risk, biliary sphincterotomy with endoscopic duct clearance alone may be considered as an alternative to cholecystectomy 1

Hyperkinetic Gallbladder (GBEF ≥80%)

• Proceed with laparoscopic cholecystectomy for patients with confirmed hyperkinetic gallbladder and biliary-type pain meeting Rome III criteria 7, 8
• Surgical intervention provides significant symptomatic relief in these patients 8

Medical Dissolution Therapy (Limited Role)

Ursodiol for Stone Dissolution

• Ursodiol 8-10 mg/kg/day in 2-3 divided doses can be used for radiolucent gallbladder stones 9
• Complete stone dissolution occurs in only 30% of unselected patients with uncalcified stones <20 mm treated for up to 2 years 9
• Stone recurrence occurs in up to 50% of patients within 5 years after complete dissolution 9
• This approach is rarely used in practice given the high efficacy and low morbidity of laparoscopic cholecystectomy

Critical Pitfalls to Avoid

• Do not routinely place biliary stents before assessing resectability except for acute cholangitis, severe malnutrition, or specific technical indications 1
• Do not assume atypical or ambiguous symptoms will resolve with cholecystectomy; these patients have lower success rates 1
• Do not use routine postoperative antibiotics when the infectious focus is controlled by cholecystectomy in uncomplicated cases 1
• Avoid fluoroquinolones as first-line due to high resistance rates and unfavorable side effects; reserve for specific cases only 1