ABDOMINAL PAIN
Suspect gallstone disease in people who present with the classical
symptoms and signs of symptomatic gallstone disease or complications
of gallstone disease.
Biliary colic — this is the most common presentation. Steady
non-paroxysmal biliary pain occurs in the epigastrium or right
upper quadrant and typically lasts for more than 30 minutes,
but less than 8 hours. It is often severe and may be associated
with nausea and vomiting, but is not associated with fever or
abdominal tenderness.
§ Pain of shorter duration (less than 30 minutes) is less
likely to be biliary colic.
o Acute cholecystitis — this is the second most common
presentation. Classical symptoms and signs are similar to
biliary colic, but in addition other classical features are fever
and tenderness in the right upper quadrant.
o Obstructive jaundice — yellowish discolouration of the skin,
dark urine, and pale stools.
o Cholangitis — typical features, referred to as Charcot's triad,
are diagnostic: fever (often with rigors), jaundice, and upper
quadrant abdominal pain.
o Gallstone pancreatitis — constant epigastric pain radiating
through to the back and profuse vomiting.
o Various other complications can cause a variety of symptoms.
§ Features that suggest the presence of complications
include fever, rigors, hypotension, epigastric pain
radiating to the back, dark urine, jaundice, Murphy’s sign
(tenderness in the right upper quadrant below the costal
margin on deep inspiration), diffuse abdominal
tenderness, or a positive result for urine bile pigments on
urinalysis.
Some people with gallstone disease do not have classical
symptoms or signs and present with mild and varied symptoms
such as indigestion, intolerance to fried or fatty food, or epigastric
pain.
o Consider gallstone disease in any person with any abdominal
symptom that is not confirmed to be due to another cause.
Gallstones may be detected as an incidental finding on abdominal
ultrasound or X-ray examination.
If gallstone disease is suspected in primary care, or people
with abdominal or gastrointestinal symptoms have been
unresponsive to previous management, offer:
o
•
•
•
An abdominal ultrasound examination — this may confirm the
presence of one or more gallstones.
§ The absence of stones on an ultrasound scan does not
exclude their existence.
o Liver function tests (LFTs) — gallstones in the common bile
duct may result in abnormal LFTs.
Consider referral for further investigation if results are normal
but clinical suspicion remains high. This may include:
o Magnetic resonance cholangiopancreatography (MRCP), if
ultrasound has not detected common bile duct stones, but the:
§ Bile duct is dilated and/or
§ Liver function test results are abnormal.
o Endoscopic ultrasound (EUS) if MRCP does not allow a
diagnosis to be made.
Refer people for further investigations if conditions other than
gallstone disease are suspected.
o
•
•
Management
Asymptomatic
For a person with
asymptomatic gallstones
in a normal gallbladder
and normal biliary tree:
•
o
o
o
Reassure
them that
they do not
need
treatment
unless they
develop
symptoms.
Explain that
asymptomati
c gallstones
are very
common.
Prophylactic
treatments
aimed at
preventing
future
complication
for a person with
asymptomatic
gallstones found
in the common
bile duct
• Offer
referral for
bile duct
clearance
and
laparoscopi
c
cholecystec
tomy —
although
they are
asymptoma
tic, there is
a significant
risk of
developing
serious
complicatio
ns such as
cholangitis
Symptomatic
•
•
Arrange emergency
admission for people
who are systemically
unwell with a
suspected complicati
on of gallstone
disease, such as
acute cholecystitis,
cholangitis, or
pancreatitis.
Refer urgently (to
gastroenterology or a
surgical service with
expertise in
managing biliary
diseases):
o People with
known
gallstones and
jaundice, or if
there is a
clinical
s are not
recommende
d (such as
prophylactic
cholecystect
omy) as the
risk of
complication
s from
surgical
treatment
outweighs
the potential
risk of
developing
complication
s from the
stones.
§ Prophyl
actic
cholecy
stecto
my in
asympt
omatic
gallsto
ne
disease
may be
consid
ered fo
r
people
with a
partiall
y
calcifie
d
'porcel
ain'
gallbla
dder.
or
pancreatitis.
•
•
suspicion of
biliary
obstruction
(for example,
significantly
abnormal liver
function
tests).
Refer all other people
diagnosed with
symptomatic
gallstone disease to
a surgeon to
consider
laparoscopic cholecy
stectomy.
o The urgency of
referral
depends on
clinical
judgement.
Secondary care
options include
offering:
o Early
laparoscopic
cholecystecto
my (to be
carried out
within 1 week
of diagnosis)
for people
with acute
cholecystitis.
o Day-case
laparoscopic
cholecystecto
my as an
elective
planned
procedure,
unless their
circumstances
or clinical
condition
make an
inpatient stay
necessary.
Percutaneous
cholecystosto
my to manage
gallbladder
empyema
when:
§ Surgery
is
contrain
dicated
at
present
ation
and
§ Conserv
ative
manage
ment is
unsucc
essful.
o Bile duct
clearance and
laparoscopic
cholecystecto
my to people
with
symptomatic
or
asymptomatic
common bile
duct stones.
Offer appropriate
pain relief while
awaiting secondary
care assessment:
o For severe
pain,
administer a
parenteral
analgesic for
rapid relief:
§ Diclofen
ac
75 mg
intramu
scularly
unless
contrain
dicated.
o
•
§
o
A
second
75 mg
dose
may be
given
after
30 minu
tes if
necess
ary.
Conside
r an
opioid
intramu
scularly
(for
exampl
e
morphi
ne or
pethidin
e) if
diclofen
ac is
not
suitable
, or if it
is not
providin
g
adequat
e pain
relief.
This
may be
used
alone or
in
combin
ation
with
diclofen
ac if
appropr
iate.
For
intermittent
mild to
•
•
moderate
pain, offer
paracetamol
or a
nonsteroidal
antiinflammatory
drug (NSAID);
for example,
diclofenac,
which can be
given orally or
rectally if
nausea is a
problem. For
more
information,
see the CKS
topics
on Analgesia mild-tomoderate
pain and NSAI
Ds prescribing
issues.
o If pain cannot
be managed in
primary care
refer to
hospital as an
emergency.
Consider
recommending a
low-fat diet to help
prevent biliary pain.
Signpost to the NHS
England Decision
support tool: making
a decision about
gallstones.
•
o
.
What advice should I give people with symptomatic gallstones?
•
Advise people with symptomatic gallstones to:
o Avoid food and drinks that trigger their symptoms until they
have their gallbladder or gallstones removed, but they do not
need to avoid these foods and drinks after surgery.
o Seek further advice if eating or drinking triggers existing
symptoms or causes new symptoms to develop after they have
recovered from having their gallbladder or gallstones removed.
Subject: gastrointestinal upper tract cancer
Subject: gastrointestinal inferior tract cancer
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