WordNet

acute abdominal pain (especially in infants) (同)intestinal colic, gripes, griping
a pass between mountain peaks (同)gap
relating to the bile ducts or the gallbladder

PrepTutorEJDIC

腹痛,さしこみ
(山脈の)鞍部(あんぶ),山あい

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2016/06/25 02:17:15」(JST)

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Biliary colic is the term used to describe a type of pain related to the gallbladder that occurs when a gallstone transiently obstructs the cystic duct and the gallbladder contracts.^[1] Cholelithiasis refers to the presence of gallstones and cholecystitis to the inflammation associated with irritation of the viscera secondary to obstruction of the cystic duct by gallstones.

Pathophysiologically, gallstone formation occurs from the precipitation of crystals that aggregate to form macroscopic stones. The most common form is cholesterol gallstones.^[2] Other forms include calcium, bilirubin, pigment and mixed gallstones.^[2]

Signs and symptoms

Pain is the most common presenting symptom. It is usually described as sharp right upper quadrant pain that radiates to the right shoulder, or less commonly, retrosternal.^[3] Nausea and vomiting can be associated with biliary colic. Individuals may also present with pain that is induced following a fatty meal and the symptom of indigestion. The pain often lasts longer than 30 minutes, up to a few hours.^[3] Patients usually have normal vital signs with biliary colic whereas patients with cholecystitis are usually febrile and more ill appearing. Lab studies that should be ordered include a complete blood count, liver function tests and lipase. In biliary colic lab findings are usually within normal limits. Alanine aminotransferase and aspartate transaminase are usually suggestive of liver disease whereas elevation of bilirubin and alkaline phosphatase suggests common bile duct obstruction.^[4] Pancreatitis should be considered if the lipase value is elevated; gallstone disease is the major cause of pancreatitis.

Causes

Biliary pain is most frequently caused by obstruction of the common bile duct or the cystic duct by a gallstone. However, the presence of gallstones is a frequent incidental finding and does not always necessitate treatment, in the absence of identifiable disease. Furthermore, biliary pain may be associated with functional disorders of the biliary tract, so called acalculous biliary pain (pain without stones), and can even be found in patients post-cholecystectomy (removal of the gallbladder), possibly as a consequence of dysfunction of the biliary tree and the sphincter of Oddi. Acute episodes of biliary pain may be induced or exacerbated by certain foods, most commonly those high in fat.^[5]

Risk factors

Cholesterol gallstone formation risk factors include age, female sex, family history, race (e.g. higher incidence in aboriginals),^[3] pregnancy, parity, obesity, oral contraceptives, diabetes mellitus, cirrhosis, prolonged fasting, rapid weight loss, total parenteral nutrition, ileal disease and impaired gallbladder emptying.^[6]

Patients that have gallstones and biliary colic are at increased risk for complications including cholecystitis.^[7] Complications from gallstone disease is 0.3% per year and therefore prophylactic cholecystectomy are rarely indicated unless part of a special population that includes porcelain gallbladder, individuals eligible for organ transplant, diabetics and those with sickle cell anemia.^[3]

Diagnosis

Diagnosis is guided by the person's presenting symptoms and laboratory findings. The gold standard imaging modality for the presence of gallstones is ultrasound of the right upper quadrant. There are many reasons for this choice including no exposure to radiation, low cost, and availability in city, urban and rural hospitals. Gallstones are detected with a specificity and sensitivity of greater than 95% with ultrasound.^[8] Further signs on ultrasound may suggest cholecystitis or choledocholithiasis.^[9] Computed Topography (CT) is not indicated when investigating for gallbladder disease as 60% of stones are not radiopaque.^[9] CT should only be utilized if other intraabdominal pathology exists or the diagnosis is uncertain.^[10] Endoscopic retrograde cholangiopancreatography (ERCP) should be used only if lab tests suggest the existence of a gallstone in the bile duct.^[9] ERCP is then both diagnostic and therapeutic.

Management

Medical

Relief of symptoms is the initial management of symptoms. These include correcting electrolyte and fluid imbalance that may occur with vomiting.^[4] Antiemetics, such as dimenhydrinate, also known as gravol, are used to treat the nausea.^[4] Pain is usually corrected with anti-inflammatories, NSAIDs such as ketorolac and diclofenac; or in the acute setting, narcotics, such as morphine, less commonly may be used.^[11] NSAIDs are more or less equivalent to opioids (narcotics).^[12]

In biliary colic, infection is not a concern, as this would result in cholecystitis, and therefore antibiotics are not required.^[13]

Surgical

Treatment is dictated by the underlying cause. The presence of gallstones, usually visualized by ultrasound, generally necessitates a surgical treatment (removal of the gall bladder, typically via laparoscopy). Removal of the gallbladder with surgery, known as a cholecystectomy, is the definitive treatment for biliary colic. Tentative evidence suggest that early gallbladder removal may be better than delayed removal.^[14] Early laparoscopic cholescystectomy happens within 72 hours of diagnosis.^[9] In a Cochrane review that evaluated receiving early versus delayed surgery, they found that 23% of patients who waited on average 4 months ended up in hospital for complications, compared to no patients with early intervention with surgery.^[9]^[14] Early intervention has other advantages including reduced number of visits to the emergency department, less conversions to an open surgery, less operating time required, and reduced time in hospital post operatively.^[9]

Complications

The presence of gallstones can lead to inflammation of the gall bladder (cholecystitis) or the biliary tree (cholangitis) or acute inflammation of the pancreas (pancreatitis). Rarely, a gallstone can become impacted in the ileocecal valve that joins the caecum and the ileum, causing gallstone ileus (mechanical ileus).^[3]

Complications from delayed surgery include pancreatitis, empyema (collection of pus) or perforation of the gallbladder, cholecystitis, cholangitis, and obstructive jaundice.^[9]

Biliary pain in the absence of gallstones, known as postcholecystectomy syndrome, may severely impact the patient's quality of life, even in the absence of disease progression.^[15]

Epidemiology

The annual risk of developing biliary colic is 2 to 3%.^[3]^[7]

References

^ Auerbach, Paul S. (2012). Wilderness medicine. Philadelphia, PA: Elsevier/Mosby. pp. 411–433. ISBN 978-1-4377-1678-8.
^ ^a ^b Sabiston, David C.; Townsend, Courtney M. (2012). Sabiston textbook of surgery : the biological basis of modern surgical practi. Philadelphia, PA: Elsevier Saunders. pp. 328–358. ISBN 978-1-4377-1560-6.
^ ^a ^b ^c ^d ^e ^f Portincasa, P.; Moschetta, A.; Petruzzelli, M.; Palasciano, G.; Di Ciaula, A.; Pezzolla, A. (2006). "Gallstone disease: Symptoms and diagnosis of gallbladder stones.". Best Pract Res Clin Gastroenterol 20 (6): 1017–29. doi:10.1016/j.bpg.2006.05.005. PMID 17127185.
^ ^a ^b ^c Rosen, Peter; Marx, John A. (2013). Rosen's emergency medicine : concepts and clinical practice. Philadelphia, PA: Elsevier/Saunders. pp. 1186–1206. ISBN 978-1-4557-0605-1.
^ Diana Rodriguez. "When Gallbladder Problems Lead to Biliary Colic". Everyday Health.
^ Walton Thomas J.; Lobo Dileep N. "Gallstones". Surgery 27 (1): 19–24. doi:10.1016/j.mpsur.2008.12.001.
^ ^a ^b Afdhal, Nezam H. (2011). Goldman: Goldman's Cecil Medicine 24th Ed. Philadelphia, PA. Elsevier Suanders. ISBN 978-1-4377-1604-7. pp. 1011–1020.
^ Fischer JE, ed (2007). Master of surgery 5th ed. Philadelphia, PA. Lippincott Williams & Wilkins.^{[page needed]}
^ ^a ^b ^c ^d ^e ^f ^g "Evidence-based current surgical practice: calculous gallbladder disease.". Journal of Gastrointestinal Surgery 16: 2011–25. Nov 2012. doi:10.1007/s11605-012-2024-1. PMID 22986769.
^ Shakespear JS, Shaaban AM, Rezvani M (2010). "CT findings of acute cholecystitis and its complications.". AJR Am J Roentgenol 194: 1523–9. doi:10.2214/ajr.09.3640.
^ Rosen, Peter; Marx, John A. (2013). Rosen's emergency medicine : concepts and clinical practice. Philadelphia, PA: Elsevier/Saunders. pp. 223–233. ISBN 978-1-4557-0605-1.
^ Colli, A; Conte, D; Valle, SD; Sciola, V; Fraquelli, M (June 2012). "Meta-analysis: nonsteroidal anti-inflammatory drugs in biliary colic.". Alimentary pharmacology & therapeutics 35 (12): 1370–8. doi:10.1111/j.1365-2036.2012.05115.x. PMID 22540869.
^ Cecil, Russell L. (Russell La Fayette); Goldman, Lee; Schafer, Andrew I. (2012). Goldman's Cecil medicine. Philadelphia: Elsevier/Saunders/. pp. 1011–1021. ISBN 978-1-4377-1604-7.
^ ^a ^b Gurusamy KS, Koti R, Fusai G, Davidson BR (2013). "Early versus delayed laparoscopic cholecystectomy for uncomplicated biliary colic". Cochrane Database Syst Rev 6: CD007196. doi:10.1002/14651858.CD007196.pub3. PMID 23813478.
^ Postcholecystectomy Syndrome at eMedicine

External links

Diagram of pain radiation

UpToDate Contents

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1. 成人における合併症のない胆石症 uncomplicated gallstone disease in adults
2. 成人における胆嚢機能障害 functional gallbladder disorder in adults
3. 急性胆嚢炎：病因、臨床的特徴、および診断 acute cholecystitis pathogenesis clinical features and diagnosis
4. 総胆管結石症：臨床症状、診断、およびマネージメント choledocholithiasis clinical manifestations diagnosis and management
5. 消化不良成人患者へのアプローチ approach to the adult with dyspepsia

English Journal

Cholecystitis after yttrium-90 resin microsphere radioembolization treatment: Clinical and pathologic findings.

Parakh S1, Gananadha S2, Allen R3, Yip D4.
Asian journal of surgery / Asian Surgical Association.Asian J Surg.2016 Jul;39(3):144-8. doi: 10.1016/j.asjsur.2015.04.002. Epub 2015 Jun 23.
BACKGROUND: Radioembolization with yttrium microspheres is an established therapeutic modality for primary and secondary hepatic malignancies, with studies demonstrating improved overall survival. There remains a paucity of data on cholecystitis as a complication of radioembolization. We describe a
PMID 26116405

Functional gallbladder disease: Operative trends and short-term outcomes.

Thiels CA1, Hanson KT2, Chawla KS3, Topazian MD4, Paley KH5, Habermann EB2, Bingener J6.
Surgery.Surgery.2016 Jul;160(1):100-5. doi: 10.1016/j.surg.2016.03.005. Epub 2016 Apr 26.
BACKGROUND: Due to increasing rates of functional gallbladder disease (FGBD), we used national data to compare rates, patient characteristics, and outcomes of cholecystectomy for FGBD with the more defined diagnosis of biliary colic.METHODS: The American College of Surgeons National Surgical Quality
PMID 27129932

Histopathological examination of specimen following cholecystectomy: Are we accepting resect and discard?

Wrenn SM1, Callas PW2, Abu-Jaish W2.
Surgical endoscopy.Surg Endosc.2016 Jun 20. [Epub ahead of print]
BACKGROUND: Cholecystectomy is one of the most commonly performed general surgery procedures in the USA. It is most frequently performed for benign biliary disease such as biliary colic or cholecystitis; however, resected specimens are frequently sent for histopathological analysis due to the percei
PMID 27324336

Japanese Journal

腹腔鏡補助下結腸切除を施行した特発性腸間膜静脈硬化症の1例

日本腹部救急医学会雑誌 35(7), 951-954, 2015
NAID 130005132558

セフトリアキソン中止後長期残存した偽胆石による急性胆囊炎・胆管炎の1例

Progress of Digestive Endoscopy 87(1), 136-137, 2015
NAID 130005119125

胆管結腸瘻を合併した胆嚢欠損症の1例

日本消化器外科学会雑誌 45(2), 176-182, 2012
NAID 130004560791

Related Pictures

★リンクテーブル★

リンク元	「低カルシウム血症」「胆石疝痛発作」「胆道疝痛」
関連記事	「colic」「biliary」「coli」

「低カルシウム血症」

Biliary colic
	Biliary colic is often related to gall bladder stones
Classification and external resources
Specialty	gastroenterology
ICD-10	K80.5
ICD-9-CM	574.20
DiseasesDB	2533
eMedicine	med/224
	[edit on Wikidata]

　　[★]

英: hypocalcemia
同: 低Ca血症
関: カルシウム

血清カルシウム：8.0 mg/dl以下

病態生理

低カルシウム血症　→　2価陽イオンによる膜安定効果が消失(遮蔽効果↓、結合効果↓)　→　細胞膜の脱分極傾向 (SP.99)

病因

原発性副甲状腺機能低下症（PTHの分泌低下）DiGeorge症候群、自己免疫性
副甲状腺ホルモン受容体異常
高リン血症

腎不全→高リン血症→相対的低Ca血症

ビタミンDの欠乏：腎不全→活性型にする酵素は腎臓にあるので活性化されない。

ネフローゼ症候群、Fanconi症候群

過換気症候群：呼吸性アルカローシスにより一過性に低カルシウム血症をきたしうる。

新生児

QB.O-84

未熟児、母体糖尿病児、帝王切開児に多い

心電図パーフェクトマニュアル.221

低カリウム血症

症候

精神・神経：
筋と神経の被刺激性の亢進：筋緊張の亢進(テタニー)、腱反射亢進、クヴォステク徴候、トルソー徴候、異常感覚、情緒不安定
消化器：(時に)嘔吐、下痢。

急性症状

参考1

眼：乳頭浮腫

神経・筋の易刺激性(テタニー)

感覚異常(口・四肢)、筋痙攣、手・足の攣縮(carpopedal spasm)、トルソー徴候(手の症状)、クヴォステク徴候(顔面神経の)、てんかん発作、喉頭痙攣、気管支痙攣

心臓：QT延長、低血圧、心不全、不整脈　　←　心収縮力低下

慢性症状

参考1

異所性石灰化(大脳基底核)　　←　　P優位なCa・P積の上昇

錐体外路症状
パーキンソン症候群
認知症

嚢下白内障(subcapsular cataract)
歯牙異常
皮膚乾燥

テタニー

参考1

低カルシウム血症により末梢神経・筋肉の易刺激性亢進。EMG上、1つの刺激で高頻度の放電が見られる。テタニーはイオン化Ca 4.3mg/dL、カルシウム7.0-7.5 mg/dL未満で起こるのが一般的。テタニーは慢性腎不全(低カルシウム血症＋代謝性アシドーシス)では稀
最初は口の周りあるいは末梢の錯感覚(paresthesia)ではじまる。ぎこちなさとこわばり、筋痛、および筋攣縮・筋痙攣を呈する。呼吸筋と舌の攣縮はチアノーゼを起こしうる。自律神経の症状は発汗、期間攣縮、胆道疝痛 biliary colicを含む。　←　オッディ括約筋が収縮して腹痛を生じるらしい(080A040)

検査

Chvostek徴候；耳介の前方、顎関節の上の部分をハンマーで軽くたたくと顔面筋と眼輪筋の痙攣が起こる。
Trousseau徴候；上肢の血圧計マンシェットを巻き、収縮期と拡張期の中間血圧で１～２分圧迫すると上肢の筋の攣縮により、手首と親指が屈曲し他の手指は伸展して手掌が凹む。

心電図

QT延長　→　心室細動リスク

QTの延長はSTの延長による。T波の幅は変えないので、心房全体の再分極相の不均一化は起こりにくい。だからQT延長で多形性心室頻拍が起こることは少ないらしい(心電図の読み方 p.221-223)。

STの延長 = 2相(プラトー相)　絶対不応期と考えられる。

T波 = 3相　受攻期　相対不応期にあたる。ここが延長しなければ不整脈のリスクは高くないということか・・・ほんと？

QRS幅の拡大は伴わない

治療

グルコン酸カルシウム、活性型ビタミンD

腎臓内科レジデントマニュアル p.47

軽症：補正Ca＞8mg/dL

食事あるいはサプリメントでのカルシウム経口摂取 1日1000mg以上

無症候性で中等度(補正Ca濃度＜8mg/dL)の場合

炭酸カルシウム 3-6g
ビタミンD製剤：アルファカルシドール、ロカルトロール(アルファカルシドールの半量でよい)

アルファカルシドール 2-6μg/日特発性副甲状腺機能低下症
アルファカルシドール 1-3μg/日偽性副甲状腺機能低下症

→尿Ca/Cre比が0.3g/gCreを越えないように注意する

高度(補正Ca濃度＜7mg/dL)の場合

1. カルチコール 10-20mlを5分程度以上掛けて静注する
2. カルチコール 2-4ml/hrでCVからDIV
1. or 2.に加え)炭酸カルシウム9-12g/日、ビタミンD(アルファカルシドール 3μg/日)を開始して徐々にカルチコールを減少させる。また低マグネシウム血症があれば硫酸マグネシウムIV