Colic, Cholecystitis or Cholangitis: What difference does it make?

James A. Harris, MD, FACS

Gallstones can present in a variety of ways. Reviewing the pathophysiology of gallstone disease greatly enhances the understanding of the symptoms and treatment.

Biliary colic is pain caused by gallstones. It is typically epigastric or RUQ abdominal pain which radiates to the back. It is caused by obstruction of the cystic duct by a gallstone. It frequently occurs when the gallbladder contracts (after meals), but can occur anytime. It lasts from 20 minutes to 2 - 3 hours. Abdominal exam may be unimpressive. When the gallstone dislodges or the gallbladder stops contracting, the pain subsides. There should be little or no inflammation or infection. WBC and LFT's are normal. Treatment is elective laparoscopic cholecystectomy.

Acute Cholecystitis starts as biliary colic. The gallstone remains impacted. Pressure builds in the gallbladder leading to inflammation and then infection. Pain persisting more than 4 hours usually indicates cholecystitis. Tenderness is present in the RUQ. WBC is elevated. Mild elevation of LFT's , if present, is due to local inflammation. Treatment is admission to the hospital, IV fluids and antibiotics, bowel rest and laparoscopic cholecystectomy within a few days.

Acute Cholangitis is much less common, but can have a much more dramatic presentation. Cholangitis is infection within the common bile duct. It is caused by obstruction of the distal CBD by a gallstone that has passed through the cystic duct. Presenting symptoms include RUQ pain and tenderness, fever and jaundice (Charcot's triad). WBC count is elevated as are LFT's (T. Bili > 3, Alk Phos > ). Treatment includes stabilization with IV fluids, broad spectrum antibiotics and timely (within 12 to 36 hours) relief of the biliary obstruction (i.e. drainage of the biliary abscess). If possible, ERCP is performed with removal of CBD stones and possibly placement of stent. Alternatively, percutaneous transhepatic cholangiography (PTC) and external drainage can provide drainage and temporize until more definitive treatment can be offered. Open cholecystectomy and CBD exploration is done only if ERCP and PTC are not successful. Ideally, cholecystectomy is delayed until the septic process is resolved.

Biliary Pancreatitis is usually caused by the passage of one or more small gallstones through the ampulla of Vater into the duodenum. Epigastric pain radiating to the back is most common. Amylase and lipase are usually more than 3-500. Treatment is bowel rest, IV fluids and laparoscopic cholecystectomy when the pancreatitis has abated (usually a few days). Intraoperative cholangiogram is added or whenever there is any suspicion of CBD stones (biliary pancreatitis, elevated LFT's, history of dark urine or clay colored stools, etc.)

Significant advances in management of gallstone disease have been made with the advent of laparoscopy. The laparoscopic approach has clear advantages when compared with the open approach with respect to postoperative recovery and complications. Experience with advanced laparoscopic techniques allows the removal of even severely inflamed gallbladders. Advanced laparoscopic techniques have also allowed CBD exploration and removal of CBD stones. This is performed with a laparoscopic choledochoscope with is placed through a laparoscopic trocar, through an opening in the cystic duct and into the CBD. Extraction of stones is done under direct vision using retrieval baskets placed through the choledochoscope. These minimally invasive techniques can prevent the need for the traditional open operation and allow the patient to benefit from the enhanced postoperative recovery and decreased complications.