Gallstone disease history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

History and Symptoms

Gallstones usually remain asymptomatic initially. They start developing symptoms once the stones reach a certain size (>8mm). A main symptom of gallstones is commonly referred to as a gallstone "attack", also known as biliary colic, in which a person will experience intense pain in the upper abdominal region that steadily increases for approximately thirty minutes to several hours. A victim may also encounter pain in the back, ordinarily between the shoulder blades, or pain under the right shoulder. In some cases, the pain develops in the lower region of the abdomen, nearer to the pelvis, but this is less common.

Biliary colic

Biliary colic is pain associated with irritation of the viscera secondary to cholecystitis and gallstones. Unlike renal colic, the phrase 'biliary colic' refers to the actual cholelithiasis.

Though unlike renal colic, the phrase 'biliary colic' refers to the actual cholelithiasis. Although it is frequently described as a colic, the pain is steady, starts rapidly and lasts at least 30 minutes and up to several hours. Many patients complain of right upper quadrant pain, right flank pain, or even mid chest pain with cholelithiasis. There may be irradiation to the back and shoulders and other concomitant symptoms such as vomiting and diarrhea. Fatty foods can provoke biliary pain, but this association is relatively non-specific.

Biliary pain can be associated with objective findings (dilation of the biliary tract, elevation of plasma liver enzyme concentration, elevation of bilirubin, gamma-GT and alkaline phosphatase).

Causes

Biliary pain is most frequently caused by obstruction of the common bile duct or the cystic duct by a gallstone. However, the presence of gallstones is a frequent incidental finding and does not always necessitate treatment, in the absence of identifiable disease. Furthermore, biliary pain may be associated with functional disorders of the biliary tract, so called acalculous biliary pain, and can even be found in patients post-cholecystectomy (removal of the gallbladder), possibly as a consequence of dysfunction of the biliary tree and the sphincter of oddi.

Differential Diagnosis

• Amoebic liver abscess
• Perforated peptic ulcer
• Upper small bowel obstruction.

Complications

The more serious complication is total blockage of the bile duct which leads to jaundice, which if it is not corrected naturally or by a surgical procedure can be fatal as it causes liver damage.

The presence of gallstones can lead to infection of the gall bladder (cholecystitis) or the biliary tree (cholangitis) or acute inflammation of the pancreas (pancreatitis). Rarely, an impacted gallstone can obstruct the bowel, causing gallstone ileus (mechanical ileus).

Biliary pain in the absence of gallstones may severely impact the patient's quality of life, even in the absence of disease progression.

Presentation

This condition causes crescendos of severe pain in the right upper abdomen and sometimes through to the upper back and/or right shoulder. The pain relates to the obstruction of the passage of bile and can be associated with eating fatty foods. There is usually an inflammatory component to the pain as the characteristic colic is not completely relieved between crescendos.

Often, these attacks occur after a particularly fatty meal and almost always happen at night.

Treatment

These attacks are intensely painful, similar to that of a kidney stone attack. One way to alleviate the abdominal pain is to drink a full glass of water at the start of an attack to regulate the bile in the gallbladder, but this does not work in all cases. Another way is to take magnesium followed by a bitter liquid such as coffee or swedish bitters an hour later. Bitter flavors stimulate bile flow. A study has found lower rates of gallstones in coffee drinkers.

Pain management is an important part of treating biliary colic. Treatment is often with NSAIDs such as ketorolac (Toradol) and diclofenac (Voltaren). Hyoscine butylbromide (Buscopan) is occasionally used but is less effective than analgesics.

Other symptoms

Other symptoms include

• Jaundice
• Nausea and vomiting
• Diarrhea
• Bleeding caused by continuous vomiting
• Dehydration caused by the nausea and diarrhea.
• Abdominal bloating
• Intolerance of fatty foods
• Belching
• Indigestion.

If the above symptoms coincide with chills, lowgrade fever, yellowing of the skin or eyes, and/or clay-colored stool, a doctor should be consulted immediately.

Some people who have gallstones are asymptomatic and do not feel any pain or discomfort. These gallstones are called "silent stones" and do not affect the gallbladder or other internal organs. They do not need treatment.