Pediatric emergency medicine trisk 2076 2076
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The pain of biliary colic is acute in onset, often follows a meal, and is
usually localized to the epigastrium or right upper quadrant. Some children
localize the pain to the periumbilical area. In contrast to the colicky pain of
intestinal or ureteral origin, biliary colic does not worsen in relatively short
cyclic paroxysms or bursts but instead is characterized by its sustained,
intense quality. Unlike pancreatitis, the patient tends to move about restlessly
and the pain is not improved by changes in position. In addition, referred pain
is common, particularly to the dorsal lumbar back near the tip of the right
scapula. Nausea and vomiting are commonly associated with biliary colic but
are not severe and protracted as seen with pancreatitis. Mild jaundice occurs in
25% of patients. An attack of acute cholecystitis begins with biliary colic,
which increases progressively in severity or duration. Pain lasting longer than
4 hours suggests cholecystitis and the temperature is usually mildly elevated.
As the inflammation worsens, the pain changes character, becoming more
generalized in the upper abdomen and increased by deep respiration and
jarring motions.
In contrast, acute cholangitis should be suspected in the patient who has
right upper quadrant abdominal pain, shaking chills with spiking fever, and
jaundice (Charcot triad). These patients usually have a history of abdominal
surgery. A dangerous aspect of this disorder is that overwhelming sepsis can
develop rapidly. Listlessness and shock are characteristic of advanced or
severe cholangitis and usually reflect gram-negative septicemia. Cholangitis
can evolve rapidly before the development of significant jaundice. Clinically
apparent jaundice may be absent even in postsurgical BA patients.
Laboratory tests are typically nonspecific in cholecystitis. A CBC and blood
smear may show evidence of hemolysis. The leukocyte count averages 12,000
to 15,000 per mm3 with a neutrophilic leukocytosis. Elevated leukocyte
counts raise concern for cholangitis. The level of serum bilirubin may be
elevated but rarely exceeds 4 mg/dL. Higher values are more compatible with
either complete common bile duct obstruction or cholangitis. The levels of
serum transaminases (ALT and AST) and alkaline phosphatase may be mildly
elevated but are often normal. Marked elevation in the levels of transaminases
may occur with acute, complete common duct obstruction. Serum amylase
levels may be mildly elevated without other evidence of pancreatitis.
The general management guidelines for the ED provider include
discontinuation of oral intake, support with IV fluids, pain control, and
surgical consultation. If acute cholangitis is suspected, antibiotics should be
