biliary colic in the ED

[sixstring]

I'm a 4th year EM bound student. I'd like to get a surgeon's perspective on consults for biliary colic in the ED. Assuming a patient has known gallstones, is symptomatic from them without evidence of obstruction, cholecystitis, pancreatitis etc, when do you want to be consulted to see them?

I ask because I have seen it go both ways. Some ED physicians will consult gen surg if we see stones on ultrasound and they have colic. Others will discharge with something for pain and a telephone number for a general surgeon associated with the hospital whom they can see in clinic in a few days. Personally I've had it go both ways on the telephone with surgical residents. I've had some that will come down and see the patient without any push back, and others who are obviously irritated that I'm calling them and want to know "what I want them to do about it."

So if you could help me understand, from the spectrum of gallbladder disease of incidental gallstones all the way through impacted stones/rupture of gallbladder, what should I know about calling surgeons, and is there any hard-fast rule when I can discharge without consulting.

I don't want to be a crappy physician, and I want to understand what is happening on a fundamental level so I am more efficient, don't waste peoples time, and do the most for my patients. Thank you.

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[SouthernSurgeon]

Short answer? It depends.

Long answer? It really depends.

A ton of this will be determined by the practice patterns at your institution, both among the ED staff and among the surgeons. While there is variation from practitioner to practitioner, institutional culture tends to keep everyone working within about one standard deviation of each other when it comes to stuff like this. So I wouldn't worry too much about this as you'll see what the habits are of those around you.

For true biliary colic (i.e. no fevers/WBC count, no elevated bill or amylase/lipase, imaging showing stones only and no signs of cholecystitis, stones are mobile and not a big stone lodged in the neck, common duct is WELL VISUALIZED and normal caliber)? If their pain has resolved, it's probably reasonable to discharge them with a referral to a general surgeon in clinic.

For anything else (pain not resolving, concern for cholecystitis, etc) - probably time to call. However I think it is reasonable to get a better workup first, since not everything needs to come to a surgeon straightaway (e.g. choledocholithiasis or cholangitis -> should probably go to GI first and not surgery since they need duct clearance). Usually I tell the ED residents I'm happy to get involved before it reaches the stage of getting a HIDA scan - since I think we get too many of these scans at my institution when it wouldn't change my decision making, and the scan takes forever (esp if they have to do delays, administer morphine, etc).

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Here is my basic decision making algorithm...which I made up just now...(this all assumes adequate diagnostic workup to lump patients into these appropriate categories):
1. Biliary colic: Mild/resolved -> Refer to surgeon (*however if they call me for a consult I will see it and try to expedite/book for OR, as often as the next day if they are a reasonable operative risk candidate). Severe/non-resolving -> consult surgery
2. Cholecystitis or concern for cholecystitis: Consult surgery. In select patients where clinical suspicion for cholecystitis is low but ultrasound has non-specific findings like wall-thickening, consider HIDA prior to consulting surgery (e.g. right heart failure patient)
3. Choledocholithiasis: Consult GI rather than surgery. This is probably highly institution dependent, but we don't do many lap common duct explorations, and I would prefer the ERCP first rather than lap chole with IOC followed by ERCP after. We will still do chole in same hospital stay, but usually the GI fellow will just call 1-2 days before they are ready for d/c and we will do it.
4. Cholangitis: Consult GI rather than surgery, needs source control via either ERCP or external biliary drainage. +/- whether they need a chole depending on etiology.
5. Gallstone panc: Consult GI rather than surgery (or just admit to medicine). Needs resuscitation and treatment for pancreatitis first and foremost. Will usually still do lap chole in same hospital stay (should be standard of care imho) but the timing of this with regard to pancreatitis resolution will vary significantly.
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There are also a lot of human factors involved - if you call at 3pm on a Wednesday with biliary colic vs 2am on a Saturday, e.g., you might get a very different response. Patient level factors come into play too...a healthy 20 year old (20 is the new 40 in the F, F, F mnemonic) vs a 60 year old with heart failure...

Finally - I wouldn't worry too much about cranky surgery residents. Surgery residents, particularly the 2s and 3s who are first contacts for consults, often don't know what's good for them. Consults are just viewed as work, and they will often push back on everything. I had an interaction with one of our 2s last month when we got a consult for biliary colic. They were raging against the consult and asking me why the patient couldn't just come back to clinic.
I said: Sam*, do you like operating?
Sam: ...Yes...
Me: How many cases do we have scheduled for tomorrow?
Sam:...None...
Me: Do you want to do a chole tomorrow?
Sam:...Yes...
Me: Then go see the patient!!@!
(*name not actually Sam)

 

[sixstring]

SouthernSurgeon - Thank you, this post is very helpful and I'll certainly keep it in mind. I've got another question just for my own edification. At what point do you consider a gallbladder to hot (infected/inflamed/whatever) to remove acutely or within a day vs starting antibiotics and operating later vs cholecystostomy.

 

[sixstring]

The data is pretty clearly in favor of early cholecystectomy rather than late.

The exception to this for me will be if there is evidence that someone has been brewing for quite a long time already before presenting or before surgical eval.

For acute chole we take it out early in almost all cases. As mentioned the exception would be someone who you think has already had 4-5 days of inflammation when we get called.

As for chole tubes - I generally dislike them but accept them as necessity in a limited number of circumstances:
1. Patient truly truly too sick for OR. The MICU patient with acalculous cholecystitis
2. The patient who you truly deem too sick to ever have their gallbladder out. I.e. chole tube for life. This is the most rare to me, and a major decision, because living with a chole tube is painful for the patients and they will all inevitably need further procedures when the tube gets clogged/dislodged/etc.
3. The patient who is too sick right now for a cholecystectomy but has a significant modifiable risk factor. For example someone with a recent MI who is on dual anti-platelet therapy for a drug eluting stent. Putting a chole tube in on someone like that may make a difference, because their risk of undergoing an operation in a few months is dramatically less than it is right now.

Awesome. Thanks for your time! The hard details I got but the subtleties have always been nebulous for me; even after rotating through surgery. This clears things up quite a bit. Cheers

 

[ACSurgeon]

Short answer? It depends.

Long answer? It really depends.

A ton of this will be determined by the practice patterns at your institution, both among the ED staff and among the surgeons. While there is variation from practitioner to practitioner, institutional culture tends to keep everyone working within about one standard deviation of each other when it comes to stuff like this. So I wouldn't worry too much about this as you'll see what the habits are of those around you.

For true biliary colic (i.e. no fevers/WBC count, no elevated bill or amylase/lipase, imaging showing stones only and no signs of cholecystitis, stones are mobile and not a big stone lodged in the neck, common duct is WELL VISUALIZED and normal caliber)? If their pain has resolved, it's probably reasonable to discharge them with a referral to a general surgeon in clinic.

For anything else (pain not resolving, concern for cholecystitis, etc) - probably time to call. However I think it is reasonable to get a better workup first, since not everything needs to come to a surgeon straightaway (e.g. choledocholithiasis or cholangitis -> should probably go to GI first and not surgery since they need duct clearance). Usually I tell the ED residents I'm happy to get involved before it reaches the stage of getting a HIDA scan - since I think we get too many of these scans at my institution when it wouldn't change my decision making, and the scan takes forever (esp if they have to do delays, administer morphine, etc).

---
Here is my basic decision making algorithm...which I made up just now...(this all assumes adequate diagnostic workup to lump patients into these appropriate categories):
1. Biliary colic: Mild/resolved -> Refer to surgeon (*however if they call me for a consult I will see it and try to expedite/book for OR, as often as the next day if they are a reasonable operative risk candidate). Severe/non-resolving -> consult surgery
2. Cholecystitis or concern for cholecystitis: Consult surgery. In select patients where clinical suspicion for cholecystitis is low but ultrasound has non-specific findings like wall-thickening, consider HIDA prior to consulting surgery (e.g. right heart failure patient)
3. Choledocholithiasis: Consult GI rather than surgery. This is probably highly institution dependent, but we don't do many lap common duct explorations, and I would prefer the ERCP first rather than lap chole with IOC followed by ERCP after. We will still do chole in same hospital stay, but usually the GI fellow will just call 1-2 days before they are ready for d/c and we will do it.
4. Cholangitis: Consult GI rather than surgery, needs source control via either ERCP or external biliary drainage. +/- whether they need a chole depending on etiology.
5. Gallstone panc: Consult GI rather than surgery (or just admit to medicine). Needs resuscitation and treatment for pancreatitis first and foremost. Will usually still do lap chole in same hospital stay (should be standard of care imho) but the timing of this with regard to pancreatitis resolution will vary significantly.
---

There are also a lot of human factors involved - if you call at 3pm on a Wednesday with biliary colic vs 2am on a Saturday, e.g., you might get a very different response. Patient level factors come into play too...a healthy 20 year old (20 is the new 40 in the F, F, F mnemonic) vs a 60 year old with heart failure...

Finally - I wouldn't worry too much about cranky surgery residents. Surgery residents, particularly the 2s and 3s who are first contacts for consults, often don't know what's good for them. Consults are just viewed as work, and they will often push back on everything. I had an interaction with one of our 2s last month when we got a consult for biliary colic. They were raging against the consult and asking me why the patient couldn't just come back to clinic.
I said: Sam*, do you like operating?
Sam: ...Yes...
Me: How many cases do we have scheduled for tomorrow?
Sam:...None...
Me: Do you want to do a chole tomorrow?
Sam:...Yes...
Me: Then go see the patient!!@!
(*name not actually Sam)

Just wanted to emphasize two things:
- Make sure you have the correct diagnosis of biliary colic. More patients actually have acute cholecystitis than you think. Giving somebody 1 mg of dilaudid and a sip of water with a cracker doesn't exactly equate to passing a PO challenge and resolution of pain.

- The institution dependent nature of triaging complicated biliary disease. At our academic hospital, we admit all gallstone pancreatitis and choledocholithiasis if we're consulted before medicine. At the community hospitals, most of these patients go to medicine with a surgery consult. Either way, for anything other than simple biliary colic, the gallbladder should come out before discharge from the hospital.

Some personal bias: hospitals with acute care surgery (or surgical hospitalist) might find that surgeons are much happier to be called for every biliary colic and will admit and operate on those patients as they come. This will be contrary to the busy surgeon with a full elective schedule being called during their elective cases/clinic to see an ED patient who doesn't really need a surgeon during this visit (i.e. just biliary colic).

When in doubt, get a consult. If you're sure it's biliary colic, no one will fault you for sending them home with f/u in surgery clinic plans.

 

[SLUser11]

I'm a 4th year EM bound student. I'd like to get a surgeon's perspective on consults for biliary colic in the ED. Assuming a patient has known gallstones, is symptomatic from them without evidence of obstruction, cholecystitis, pancreatitis etc, when do you want to be consulted to see them?

I ask because I have seen it go both ways. Some ED physicians will consult gen surg if we see stones on ultrasound and they have colic. Others will discharge with something for pain and a telephone number for a general surgeon associated with the hospital whom they can see in clinic in a few days. Personally I've had it go both ways on the telephone with surgical residents. I've had some that will come down and see the patient without any push back, and others who are obviously irritated that I'm calling them and want to know "what I want them to do about it."

So if you could help me understand, from the spectrum of gallbladder disease of incidental gallstones all the way through impacted stones/rupture of gallbladder, what should I know about calling surgeons, and is there any hard-fast rule when I can discharge without consulting.

I don't want to be a crappy physician, and I want to understand what is happening on a fundamental level so I am more efficient, don't waste peoples time, and do the most for my patients. Thank you.

I love the previous responses, and I have little to add re: the clinical side of things.

What I will say is that if you are planning a career as an EP, you should get used to people being upset that you called them. You are creating more work for them, and it's human nature to dislike that.

However, if you simply give the patient the number to make an appointment in general surgery clinic, and send them out the door, many of them (and possibly most) will never make that call. They will either wait until the pain happens again and return to an ER somewhere, or do their research online and choose another surgeon that way.

If you are a surgeon trying to make a living off of gallbags, then you should be happy to come down to the ER, introduce yourself, describe briefly for the patient what is going on and how it can be fixed, then giving them your card and arranging close follow up. If possibly, it's best if they have an appointment date prior to leaving the OR.

As I've said before, I am retired from removing gallbags, but I've certainly removed my share as a resident and young attending. Having residents makes it easier for someone to physically lay hands on the patient. Without residents, it becomes more difficult to come say hi to a patient prior to their ER dismissal, especially if this happens at 2am, and/or it happens in an ER across town from where you are currently. Although I think the entire concept of "curbside" consults is dangerous, it is reasonable in this situation to simply call the surgeon, and ask them if they'd like to see the patient prior to dismissal.

 

[dpmd]

Yeah. As a community surgeon i don't want to be called if the er is certain they want to send them home unless it is daytime but even then i am busy enough to either let them go home and see me at my next clinic day (and if they don't come to me oh well) or say hey just get them admitted to the hospitalist (culture pattern here is we don't admit anyone from the er) and i will add it on for later. Frequently the patient will have something i can latch onto to justify the admit if i ask enough questions and i certainly take care of a number of people sent home by someone who thought it was just biliary colic when the lfts were bumped or they have a white count and have been suffering with the acute chole or choledocho since then. So if they don't know how to differentiate i would rather get the call and save the patient some pain and complications.