Biliary Colic (Gallbladder Attack)

What happens in biliary colic

The gallbladder stores bile, a digestive fluid made by the liver. After you eat, especially fatty food, a hormone called cholecystokinin makes the gallbladder squeeze bile into the small intestine through the cystic duct and common bile duct.

If gallstones are present, a stone can be pushed into the narrow neck of the gallbladder or the cystic duct. The gallbladder contracts against the blockage, causing pain. When the gallbladder relaxes and the stone falls back, the pain eases.

"Colic" is misleading: biliary pain is usually steady, not coming in waves.

Symptoms

• steady, intense pain in the upper right belly or the pit of the stomach (epigastrium)
• pain spreading to the right shoulder blade or between the shoulder blades
• pain that builds over minutes, plateaus, and then fades over hours
• nausea and sometimes vomiting
• restlessness, unable to find a comfortable position
• attacks often in the evening or at night, sometimes after a large or fatty meal
• between attacks, you usually feel completely well

Bloating, belching and heartburn are often blamed on gallstones but are not reliable symptoms of gallbladder disease.

How long does a gallbladder attack last?

Most attacks last 30 minutes to a few hours. Pain lasting longer than about 6 hours, especially with fever, suggests that the stone has stayed stuck and the gallbladder has become inflamed.

Biliary colic vs cholecystitis and other complications

Causes and risk factors

Gallstones form when bile contains too much cholesterol or bilirubin, or the gallbladder does not empty well. Risk factors:

• female sex, pregnancy and estrogen therapy
• age over 40
• obesity, and rapid weight loss, including after weight-loss surgery
• family history and some ethnic backgrounds, such as Native American and Mexican American
• diabetes and metabolic syndrome
• prolonged fasting and intravenous nutrition
• conditions that break down red blood cells, such as sickle cell disease (pigment stones)
• Crohn's disease affecting the end of the small intestine, and cirrhosis

Diagnosis

• Abdominal ultrasound: the best first test. It shows gallstones in more than 95% of cases and checks for gallbladder wall thickening and duct dilation.
• Blood tests: liver function tests, bilirubin, lipase, white cell count and CRP. In uncomplicated biliary colic they are normal.
• Further imaging when needed: MRCP (an MRI of the bile ducts), endoscopic ultrasound, or a HIDA scan if cholecystitis or biliary dyskinesia is suspected.
• ECG for upper belly pain in people at risk of heart disease.

Other conditions with similar pain include peptic ulcers, reflux, kidney stones, pancreatitis, liver inflammation and heart attack.

Treatment

During an attack

• Pain relief: NSAIDs such as ibuprofen, or diclofenac or ketorolac in a clinic, are effective for biliary pain. Follow the label dose for over-the-counter products, and avoid NSAIDs with kidney disease, ulcers or blood thinners. Stronger pain relief may be needed in the ER.
• Anti-nausea medicine.
• Avoid eating until the pain settles, then start with light, low-fat food.

Preventing further attacks

After one episode of biliary colic, many people go on to have further attacks, and some develop complications. Laparoscopic cholecystectomy, keyhole removal of the gallbladder, is the standard treatment for symptomatic gallstones. It is usually a day procedure or a 1-night stay, with return to normal activities in 1 to 2 weeks.

You can live normally without a gallbladder. Bile then flows directly from the liver into the intestine. A minority of people notice looser stools after fatty meals, which usually improves over time.

Non-surgical options

For people who cannot have or do not want surgery:

• Ursodeoxycholic acid tablets can slowly dissolve small cholesterol stones over months to years, but stones often return.
• Diet: smaller, lower-fat meals may reduce attacks but do not remove the stones.
• Watchful waiting is reasonable after a single mild episode for some people.

Gallstones without symptoms

Gallstones found by chance on a scan usually need no treatment, because most never cause problems.

Diet tips

• eat regular, moderately sized meals rather than skipping meals then eating large ones
• limit fried and very fatty foods if they trigger attacks
• include fiber from vegetables, fruit and whole grains
• lose weight gradually, about 0.5 to 1 kg (1 to 2 lb) a week, rather than quickly

Frequently asked questions

What does biliary colic feel like?

It feels like a steady, intense ache or pressure in the upper right or upper middle belly, often spreading to the right shoulder blade or back. It may come with nausea and restlessness. It usually builds over minutes and settles over a few hours.

How long does a gallbladder attack last?

Typical biliary colic lasts from 30 minutes to 6 hours and then goes away completely. If pain lasts longer than 6 hours, or you develop fever or yellow skin, seek urgent care because this may be cholecystitis or a stone in the bile duct.

What triggers a gallbladder attack?

Attacks are often triggered by eating, especially large or fatty meals, which make the gallbladder contract. Many attacks also occur at night without an obvious trigger. Rapid weight loss and pregnancy increase the chance of attacks in people with gallstones.

What is the difference between biliary colic and cholecystitis?

Biliary colic is temporary pain from a stone briefly blocking the gallbladder, which settles within hours. Cholecystitis is inflammation of the gallbladder when the blockage persists, with longer-lasting pain, fever and tenderness. Cholecystitis usually needs hospital treatment.

Do I need my gallbladder removed after biliary colic?

Surgery is usually recommended after symptomatic gallstones, because attacks tend to recur and complications such as cholecystitis or pancreatitis can develop. After a single mild attack, some people choose to wait. Discuss the risks and benefits with a surgeon.