Gallbladder pain is an all-inclusive term used to describe any pain due to disease related to the gallbladder. The major gallbladder problems that produce gallbladder pain are biliary colic, cholecystitis, gallstones, pancreatitis, and ascending cholangitis.
A brief review of the gallbladder anatomy and function may help readers better understand gallbladder pain. The gallbladder is connected to the liver via ducts that supply bile to the gallbladder for storage.
These bile ducts then form the common hepatic duct that joins with the cystic duct from the gallbladder to form the common bile duct that empties into the GI tract (duodenum).
In addition, the pancreatic duct usually merges with the common bile duct just before it enters the duodenum. Hormones trigger the gallbladder to release bile when fat and amino acids reach the duodenum after eating a meal (see illustration below), which facilitates the digestion of these foods.
Gallbladder Pain Causes
The pain of gallbladder disease almost always has one of two causes – gallstones or cholecystitis. Gallstones are stones that form in the gallbladder (often misspelled “gall bladder”).
They vary in size from a millimeter or two to several centimeters and are made up of cholesterol or pigment.
Cholecystitis means inflammation of the gallbladder. Although, cholecystitis is most commonly caused by gallstones, there are other less common causes as well.
What is the mechanism of gallbladder pain?
Gallstones have a tendency to become lodged in the bile ducts leading from the gallbladder or liver, and into the intestines. When gallstones lodge in the ducts, they give rise to a specific type of pain called biliary colic.
The characteristics of biliary colic are very consistent, and it is important to recognize its characteristics because they direct the physician to the most appropriate test to diagnose gallstones, primarily abdominal ultrasonography.
In approximately 5% of cases, ultrasonography will fail to show gallstones. In such situations, if the characteristics of biliary colic are typical, physicians will go on to other more advanced tests for diagnosing gallstones, specifically endoscopic ultrasound.
Finally, most gallstones do not cause pain, and are frequently found incidentally during abdominal ultrasonography. If the symptoms for which the ultrasonography is being done are not typical of biliary colic, it is unlikely that the symptoms are caused by gallstones.
The gallstones can be truly silent. This is important to recognize because surgery to remove the gallstones is unlikely to relieve the symptoms.
When gallstones lodge suddenly in the duct leading from the gallbladder (cystic duct), the duct leading from the liver to the cystic duct (common hepatic duct), or the duct leading from the cystic duct to the intestine (common bile duct), the normal flow of bile from the liver is interrupted.
With obstruction of the common hepatic or common bile duct, the backup of bile causes the ducts (and the gallbladder in the latter case) to distend. This distention (stretching) is the cause of the biliary colic. When obstruction of the cystic duct occurs, fluid is secreted into the gallbladder causing it to distend.
Again, the distention causes biliary colic. Biliary colic stops when the gallstone unlodges from the duct.
Gallbladder Pain Characteristics
The term, biliary colic, is a misnomer, that is, it is misnamed. A colicky type of pain is a pain that comes and goes. Biliary colic does not come and go.
It may fluctuate over time in intensity, but it does not disappear. It is constant. It comes on rather suddenly, either starting as an intense pain or builds up in intensity quickly to reach a peak. It remains constant (though possibly fluctuating in intensity) and then disappears, usually gradually.
The duration of the pain is 15 minutes to several hours. If the pain is shorter than 15 minutes, it is unlikely to be caused by gallstones.
If the pain lasts longer than several hours it is either not biliary colic, or the gallstone causing the biliary colic has led to a complication, for example, cholecystitis.
The pain of biliary colic usually is severe.
Individuals with biliary colic tend to move around trying unsuccessfully to find a position of comfort.
Movement does not make the pain worse, since movement has no effect on the distended ducts or gallbladder.
It is most commonly maximal in the mid-upper abdomen (epigastrium).
The next most common location is the right upper abdomen which is actually where the gallbladder is located. (The probable explanation for this is that the gallbladder forms embryologically as a midline organ, and its supply of nerves, including pain fibers, comes from the midline of the body.
The nervous system “misidentifies” the problem causing the biliary colic as coming from the midline of the body.)
Other less common areas of maximal intensity include the left upper abdomen, and rarely the lower abdomen.
For unclear reasons, the pain may radiate (spread) to other areas, for example, the right shoulder or the tip of the right scapula; rarely these may be the areas of maximal pain.
It is widely but incorrectly believed that biliary colic occurs mostly after meals. In fact, biliary colic is more likely to occur in the evening or at night, often awakening individuals from sleep.
It appears that the ingestion of food does not cause biliary colic, even though the theory has been proposed that food causes the gallbladder to contract and push stones into the ducts.
Biliary colic is a recurring problem, but there is a tendency for episodes to occur infrequently, i.e, less than monthly.
How is the cause of gallbladder pain diagnosed?
The history and physical exam helps to establish a presumptive diagnosis. Murphy’s sign (pain or temporary respiratory arrest on deep right subcostal palpation) has been estimated to be over 95% specific for acute cholecystitis.
A few laboratory tests such as liver function tests, lipase, amylase, complete blood count (CBC), and an abdominal X-ray are done to determine the exact problem is causing the pain.
Ultrasound can detect gallstones, and CT scan may delineate organ structural changes. A HIDA scan (uses radioactive material) can measure gallbladder emptying while an ERCP test uses an endoscope to place dye in the ducts of the pancreas, gallbladder and liver.
Magnetic resonance imaging (MRI) is sometimes used to detail the organ structures (liver, gallbladder, and pancreas). The results of these tests help pinpoint the problem and establish the diagnosis.
What is the treatment of gallbladder pain?
If you have no gallbladder pain (even if you have gallstones but never had pain), you need no treatment. Some patients who have had one or two attacks may elect to avoid treatment.
Pain during an acute attack is often treated with morphine. The definitive treatment is to remove the gallbladder (and/or the obstructing gallstones) by surgery.
Currently, the surgical method of choice is laparoscopic surgery, where the gallbladder is removed by instruments using only small incisions in the abdomen.
However, some patients may require more extensive surgery. Usually, people do well once the gallbladder is removed.
Women who are pregnant are treated like women who are not pregnant, although pregnancy is a risk factor for cholesterol gallstone development.
Although supportive care is tried in women who are pregnant, acute cholecystitis is the second most common surgical emergency in pregnancy (appendicitis is the first).
Gallbladder Pain Symptoms
The most common symptom that accompanies biliary colic is nausea with or without vomiting. The vomiting does not make the pain better since it has no effect on the distended ducts or gallbladder.
Other non-specific symptoms, more likely caused as a response to pain rather than the obstruction, are:
- sweating (diaphoresis),
- light-headedness, and
- shortness of breath
Symptoms that suggest other causes for pain are pain that is maximal in the lower abdomen, abdominal bloating or belching, and abnormal bowel patterns.
What are the complications of gallbladder pain?
The complications of gallbladder pain include discomfort with eating, poor food intake, weight loss, electrolyte abnormalities, consumption of pain medications, and disruption of daily activities.
However, complications of gallbladder disease include bile duct blockage, serious infections (empyema and gangrene of the gallbladder), pancreatitis, peritonitis, and infrequently, cancer.