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Gallstones

BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39267.452257.AD (Published 09 August 2007) Cite this as: BMJ 2007;335:295

Rapid Response:

Gallstones: Why are doctors so poor at recognising biliary colic?

Dear sir/madam,

The clinical review by Sanders and Kingsnorth provides a useful
summary of the clinical spectrum of gallstone-related disease (1). While
we agree with the comment that the ‘history is crucial in diagnosing
biliary colic’ the table in the article summarising the symptoms caused by
gallstones regrettably perpetuates the incorrect belief that this pain is
‘colicky’ in nature.

The misnomer ‘biliary colic’ undoubtedly contributes to the
difficulties inexperienced doctors have in diagnosing gallstone-related
disease.

There seems to be little consensus on the definition of biliary colic
amongst doctors, but the commonly held belief that the pain is “colicky”,
always in the right upper quadrant and associated with fatty meals, is not
an accurate representation of what most patients experience. Colic is
defined as a severe paroxysmal abdominal pain, waxing and waning in
intensity, due to spasm, obstruction, or distension of one of the hollow
viscera. Biliary colic however is not colicky; the intensity of the pain
rises to a crescendo over a period of minutes to an hour and then persists
as a constant severe, pain for between one and twenty four hours before
resolving (2,3). The pain is often in the upper abdomen as stated in the
article but is not uncommonly located in the lower retrosternal region
causing confusion to the unwary casualty officer or general practitioner
who may confuse the symptoms with severe reflux or cardiac pain, although
radiation to the back is more common with biliary colic (2,3). Unlike
‘functional’ abdominal pain, biliary colic not infrequently wakes the
patient from sleep at night and is frequently severe enough to cause
vomiting (3). In between episodes, patients are usually completely free of
pain or discomfort.

We tested the ability of a group of junior doctors to diagnose
biliary colic, using questionnaires that presented three evidence-based
scenarios: one with typical features of biliary colic, one of dyspepsia
and one of gastro-oesophageal reflux disease (GORD). They were given ten
differential diagnoses and had to rank the top three most likely diagnoses
for each scenario. They were then asked to give the first line
investigation for each scenario from a list of ten investigations.

A total of 47 questionnaires were completed. Only 21% of doctors
correctly diagnosed biliary colic. Despite the classical history of
biliary colic, this was mis-diagnosed as dyspepsia in 40% of cases. GORD
was correctly identified by 69% of doctors, but only 36% correctly
diagnosed dyspeptic symptoms with 14% incorrectly attributing dyspeptic
symptoms to biliary colic.

The difficulty in distinguishing dyspepsia from biliary colic may
lead to unnecessary endoscopic examination and delayed diagnosis in
patients whose management should be directed at their gallstones.
Furthermore, ten to twenty percent of the population have cholelithiasis,
but the majority (up to 75%) of these are asymptomatic at diagnosis. Long
term follow up shows that only 10 to 25% of these will progress from
asymptomatic to symptomatic disease (4). Up to 40% of the population are
estimated to have dyspeptic symptoms at some time (5); if a significant
proportion of these patients are incorrectly diagnosed as having biliary
colic, on the basis of the presence of gallstones on ultrasound
examination and a misunderstanding of the typical history of biliary
colic, they may be submitted to unnecessary laparascopic cholecystectomy
with no resolution of symptoms.

Although based on small numbers, this study would suggest that the
majority of junior doctors are unable to recognise biliary colic, even
when presented with a patient giving a classical history. There is no
reason to assume more experienced doctors would have performed much
better.

There is clearly a need to re-examine the way medical students and
doctors are taught to differentiate different types of abdominal pain.
Finding a new term to replace ‘biliary colic’ may go some way towards
avoiding the current confusion.

Dr Heather Lewis, Specialist Registrar in Gastroenterology

Dr Alistair McNair, Consultant Gastroenterologist


Queen Elizabeth Hospital
Stadium Road
London SE18 4QH

REFERENCES

1. Sanders G, Kingsnorth AN. Gallstones BMJ 2007;335:295-9

2. Diehl AK, Sugarek NJ, Todd KH. Clinical Evaluation for Gallstone
Disease: Usefulness of symptoms and signs in diagnosis. The American
Journal of Medicine. 1990;89: 29-33

3. Romero Y, Thistle JL, Longstreth GF, Harmsen WS, Schleck CD,
Zinsmeister AR, Pardi DS, Zein CO. A questionaire for the assessment of
biliary symptoms. The American Journal of Gastroenterology. 2003; 98: 1042
-1051

4. Sakorafas GH, Milingos D, Peros G. Asymptomatic cholelithiasis: is
cholecystectomy really needed? A critical reappraisal 15 years after the
introduction of laparascopic cholecystectomy. Dig Dis Sci. 2007
May;52(5):1313-25

5. Malfertheiner P. Current concepts in dyspepsia: A world
perspective. Eur J Gastroenterology Hepatol. 1999 Jun; 11 Suppl 1: s25-9

Competing interests:
None declared

Competing interests: No competing interests

28 August 2007
Heather I Lewis
Specialist Registrar Gastroenterology
Alastair McNair
Whipps Cross University Hospital, NE11 1NJ