Melanie Jones, PA-C
Biliary disease in the outpatient setting is a common cause of abdominal pain. Abdominal pain is a common complaint for many outpatients. Your goal will be to determine if the complaint is something emergent that will require that the patient present to the Emergency Department or if it can be worked up outpatient. One of the more common outpatient complaints of abdominal pain will involve right upper quadrant pain. This location may be several different diagnoses, but the most common will a form of biliary diseases.
There are several biliary diseases that you need to be aware of: cholelithiasis (gallstones), choledocholithiasis, cholecystitis, and cholangitis. Cholelithiasis usually leads to choledocholithiasis, cholecystitis and cholangitis. Cholelithiasis occurs due to increased bile and cholesterol with pigments such as bilirubin or a combination of the two in conjunctions with delayed emptying of the gallbladder. Some patients remain asymptomatic and their gallstones are only found incidentally.
You will likely encounter cholelithiasis in the primary care setting. This can be treated outpatient as well. Symptomatic cholelithiasis is also called biliary colic and can be treated
outpatient. Symptoms will include episodic epigastric pain or right upper quadrant abdominal
pain, nausea and/or vomiting. The pain may also radiate to the back, tip of right scapula, right
shoulder or right flank area. Patients may experience pain after eating a fatty meal as well. Their symptoms and pain usually last for 4-6 hours. Some patients will experience atypical symptoms and you need to evaluate this further even if they have a history of cholelithiasis with confirmation on imaging. These atypical symptoms can include abdominal distention and bloating, chest pain, epigastric or retrosternal burning, fullness after meals, nausea or vomiting without other symptoms, nonspecific abdominal pain and regurgitation.
Choledocholithiasis, Cholangitis, and Cholecystitis
Cholelithiasis can be monitored and treated in the outpatient setting. Choledocholithiasis, cholangitis and cholecystitis will require inpatient evaluation. If you suspect any of these and the patient presents with prolonged or continuous symptoms for more than 6 hours, send the patient to the Emergency Department for workup. Be aware of patients presenting with Charcot’s Triad for cholangitis: right upper quadrant abdominal pain, fever and jaundice. Severe cases may also present with the Reynold’s Pentad: right upper quadrant abdominal pain, fever, jaundice and confusion.
The examination always plays an important part in your diagnosis. Murphy’s sign is a huge component of a proper exam in biliary disease. Some people mistakenly think that Murphy’s sign is just pain with palpation of the right upper quadrant. You need to make sure that you are performing it correctly. Have the patient fully exhale, place your hand at the midclavicular line of the right costal margin and then have the patient inhale. With the inhalation your hand will be in contact with the gallbladder. If the patient stops during inhalation and/or winces with pressure in the right upper quadrant then this is a positive Murphy’s sign. However, they must not have the same pain when the maneuver is done in the left upper quadrant for it to truly be a positive Murphy’s sign.
Routine laboratory testing can be done in the outpatient setting if you are not concerned about infection or if symptoms are not severe. Labs can also be very helpful in differentiating cholelithiasis from cholangitis, cholecystitis and choledocholithiasis. Routine labs that are ordered are CBC (to check the white blood cell count), Transaminases (AST/ALT), Bilirubin, Alkaline phosphatase, Amylase and Lipase.
If you are in an outpatient setting you will likely be looking for signs of cholelithiasis.
In cholelithiasis WBC will generally be normal, AST/ALT will be normal or slightly elevated,
Bilirubin will be normal, Alkaline phosphatase will be normal or slightly elevated and Amylase and Lipase will be normal.
Diagnostic Imaging of Biliary Disease
In addition to labs, diagnostic testing should be done for patients presenting with concerns of biliary disease. If you are concerned about a possible acute abdomen, send your patient directly to the ER. If you suspect possible cholelithiasis then abdominal ultrasound can be done. Abdominal ultrasound is also the initial diagnostic study of choice for outpatients. It is sensitive enough to pick up gallstones and if you have a portable point of care ultrasound in your office, such as the Butterfly, you may be able to determine gallstones before the patient leaves the visit.
The ultrasound may also pick up something called a “porcelain gallbladder” which is calcification of the bladder which is believed to be caused by excessive and recurrent gallstones. It is also a sign of gallbladder carcinoma.
CT scan is an option as well that may also pick up gallstones outside the gallbladder. Whichever imaging option you chose, make sure that you will be able to follow up on the findings when they result and determine possible further care from there.
Biliary Colic in Pregnancy
Pregnant patients will be treated symptomatically in the outpatient setting. Prioritize abdominal ultrasound rather than CT to avoid radiation. Remember to avoid NSAIDs during pregnancy and the patient can take Tylenol as needed. Worsening symptoms in the patient should require that patient go to nearest Emergency Department for further workup and possible treatment.
Treatment of Biliary Disease
As cholelithiasis can be symptomatic and cause biliary colic it is ideal to treat the patient based on their symptoms. You may prescribe NSAIDs, recommend over the counter NSAIDs or prescribe opioids. Although most providers are limiting opioid prescriptions, so you may be more amenable to having the patient try NSAIDs first and then reassessing at the follow up visit. Anti-emetics are suitable if the patient is experiencing nausea and/or vomiting. Patients should increase their fluid intake. Recommend that the patient drink more water rather than sugar-laden and caffeinated beverages.
You should also recommend dietary changes; patients should eat low fat foods until symptoms have resolved or improved.
General Surgery Referral
Patients with recurring cholelithiasis and biliary colic may require cholecystectomy. Refer patient to General Surgery for further workup and possible surgical intervention if they fail to
improve after outpatient symptomatic treatment. Also make sure you are referring patients with a porcelain gallbladder for evaluation by General Surgery as well.
Emergency Department Referral
If you have any concerns about the patient having biliary disease with symptoms and exam that are out of proportion to previous lab or imaging findings, send patient directly to the ED. You do not want to sit on a possible infection that could cause worsening problems or death. Also, if there any concern for sepsis with jaundice and fever, send directly to the ED.
History and physical should give your first impression for possible biliary disease. Be sure to
find out the duration of pain. If pain is lasting consistently over 6 hours, then you may want to
consider having the patient go to the nearest Emergency Department for workup rather than an outpatient workup. Look for associated symptoms of fever and jaundice as this will change your possible treatment. These symptoms lean toward cholecystitis or cholangitis.
An adequate abdominal exam is necessary. Make sure that you know and are performing the
Murphy sign correctly. It is the cessation of inhalation during palpation and not just right upper quadrant pain with palpation. Make sure to order labs and an abdominal ultrasound if you feel that this can be managed outpatient. CBC, ALT/AST, alkaline phosphatase, bilirubin, amylase and lipase labs should be normal. Dietary modification, pain control with NSAIDS, and anti-emetics are standard for symptomatic treatment. The patient should follow up with the provider in clinic. Make sure that you advise the patient to go directly to the nearest Emergency Department for any worsening symptoms.
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