The Pitt — Episode 2, ER scene:
"A 68-year-old male, history of hypertension, one hour of right upper quadrant pain after eating a fatty meal, now resolved. Afebrile, non-tender. There was a gallstone present on POCUS. EKG shows no acute ischemic changes, but I'm still waiting on LFTs and lipase." — Medical Student
Abdominal pain is one of the most common complaints in emergency departments worldwide. Mr. Milton's case in Episode 2 of The Pitt illustrates a classic presentation of a very prevalent medical condition: cholelithiasis (gallstones) causing biliary colic. The management of this case also highlights the importance of ruling out more dangerous causes, such as cardiac issues, before confirming a digestive diagnosis.
What is Cholelithiasis and Biliary Colic?
**Cholelithiasis** refers to the presence of stones within the gallbladder. The gallbladder is a small, pear-shaped organ located under the liver (in the right upper quadrant of the abdomen), responsible for storing bile, a digestive fluid produced by the liver. Gallstones form when there is an imbalance in the composition of bile, most commonly due to excess cholesterol or bilirubin, which crystallize and form solid stones. **Biliary colic** is the most common symptomatic manifestation of gallstones. It occurs when the gallbladder contracts vigorously to expel bile (usually in response to eating fatty foods), but a stone temporarily blocks the cystic duct (the tube connecting the gallbladder to the common bile duct). This blockage causes a rapid increase in pressure inside the gallbladder, resulting in severe pain.
Symptoms and Clinical Presentation
As described in Mr. Milton's case, the classic presentation of biliary colic includes: - **Right Upper Quadrant (RUQ) Pain:** Severe pain, often described as crampy or a dull ache, located on the right side of the upper abdomen, just below the ribs. The pain may radiate to the back or the right shoulder blade. - **Dietary Relationship:** The pain typically begins 30 minutes to an hour after consuming a high-fat meal (like the "fatty meal" mentioned by the student). Fat stimulates the release of cholecystokinin (CCK), a hormone that causes the gallbladder to contract. - **Duration:** The pain usually peaks rapidly and lasts from 1 to 5 hours. If the stone falls back into the gallbladder and unblocks the duct, the pain resolves spontaneously (as happened with Mr. Milton). - **Associated Symptoms:** Nausea and vomiting are very common. Crucially, in simple biliary colic, the patient is **afebrile** (no fever) and the abdomen is frequently not tender to deep palpation between pain episodes, which helps differentiate it from an acute infection.
Emergency Department Diagnosis
Diagnosis in the ER involves a combination of clinical history, imaging, and blood tests: 1. Point-of-Care Ultrasound (POCUS): As mentioned in the episode, POCUS is the initial imaging modality of choice. It is fast, non-invasive, and highly sensitive for detecting gallstones in the gallbladder. 2. Blood Tests: The student mentions waiting on "LFTs" (Liver Function Tests) and "lipase." LFTs help check if a stone has blocked the common bile duct (which would cause jaundice and altered liver enzymes). Lipase is checked to rule out pancreatitis, which can occur if a gallstone blocks the pancreatic duct. 3. The Electrocardiogram (EKG): A brilliant clinical detail in the episode is the fact that the nurse suggested an EKG. In elderly patients (Mr. Milton is 68) with a history of hypertension, upper abdominal pain can be an atypical presentation of cardiac ischemia. Ruling out a heart attack is always a priority before focusing on the gallbladder. To understand more about cardiac emergencies, see our article on Myocardial Infarction.
Complications and Progression
If a gallstone does not fall back into the gallbladder and remains impacted in the cystic duct, the condition can progress to serious complications: - **Acute Cholecystitis:** Inflammation and infection of the gallbladder. Unlike biliary colic, the pain does not go away, the patient develops a fever, and the abdomen becomes extremely tender (positive Murphy's sign). - **Choledocholithiasis:** When the stone migrates and blocks the common bile duct, causing jaundice (yellowing of the skin) and risking cholangitis (a severe infection of the bile ducts). - **Gallstone Pancreatitis:** As mentioned, if the stone blocks the drainage of the pancreas.
Treatment and Management
For a patient with simple biliary colic whose pain has already resolved (like Mr. Milton), ER management is focused on symptom control. Painkillers and antiemetics are given as needed. The definitive treatment for symptomatic gallstones is surgical: a **cholecystectomy** (gallbladder removal), often performed laparoscopically. However, for uncomplicated biliary colic, surgery is usually not done emergently in the middle of the night. The patient is often advised to maintain a low-fat diet and is referred to general surgery on an outpatient basis. (And no, Mr. Milton, you cannot have a bourbon, as alcohol and fatty snacks can trigger another attack!).
Frequently Asked Questions
Why does eating fat cause pain in someone with gallstones?
When you eat fat, your body releases a hormone that signals the gallbladder to contract and release bile to aid digestion. If there is a stone inside, this contraction pushes the stone against the exit (duct), blocking it and causing a painful buildup of pressure.
What is the difference between biliary colic and cholecystitis?
Biliary colic is temporary pain caused by a transient blockage; the pain usually passes in a few hours and there is no infection. Cholecystitis is the inflammation and infection of the gallbladder due to a prolonged blockage; the pain is constant, there is fever, and it requires antibiotics and often more urgent surgery.
Can gallstones be dissolved with medication?
There are medications (like ursodeoxycholic acid) that can dissolve small cholesterol stones over months or years, but the success rate is low and stones frequently return. Surgical removal of the gallbladder is the gold standard for definitive treatment.
Conclusion
Mr. Milton's case in The Pitt is a textbook example of diet-triggered biliary colic. It highlights the methodical workflow of emergency medicine: using bedside ultrasound to identify the anatomical cause (the gallstone), using blood tests to rule out complications (like pancreatitis), and most importantly, using the EKG to ensure that upper abdominal pain isn't a heart problem in disguise.
This content is for educational and informational purposes only. It does not replace professional medical advice, diagnosis, or treatment. In case of a medical emergency, call 911/EMS immediately or go to the nearest emergency room.
References: [1] NIDDK: Gallstones [2] UpToDate: Overview of gallstone disease [3] PubMed: Biliary Colic
