SCOPE OF THE PROBLEM
Painful biliary tract dysfunction is common. It is estimated that more than 20 million people in the United States have been treated for gall bladder disease, including 9 million who have undergone cholecystectomy. The overwhelming majority of these procedures (98%) are related to cholelithiasis, a condition that has also been reported to be present in 15% of asymptomatic adults.
Biliary colic, a term used to refer to noninflammatory, noninfectious gall bladder pain, is believed to arise from outflow tract obstruction leading to increased prostacyclin and prostaglandin elaboration. This process may result in muscular spasm of the gall bladder wall, causing both viscerally and somatically mediated pain.
Typically, biliary pain is experienced in the epigastric and right upper quadrant regions of the abdomen and may radiate to the back. In contrast to classic descriptions of colic in which minutes-long spasms of pain are considered characteristic, biliary “colic” frequently remains constant and severe for 2–3 hr or more.
Pain in biliary tract disease also often arises in association with prandial stimulation and may be associated with nausea, emesis, chest pain, and diaphoresis. Biliary colic pain due to obstruction alone is not generally associated with abdominal tenderness.
As with most abdominal processes that are evaluated and treated in the emergency department (ED), the diagnosis of biliary tract disease is often unclear on initial presentation.