Most cases of gallstones are asymptomatic meaning that there are no symptoms evident to the patient (silent gallstones). As the condition progresses, the signs and symptoms of gallstone disease may become evident, wither just the presence of pain (uncomplicated gallstone disease) or signs and symptoms due to complications like jaundice (complicated gallstone disease)
It is often thought that larger stones will cause more severe symptoms but it is the smaller stones and biliary sludge that are usually responsible for gallstone pain, attacks and the other signs and symptoms.
This is the most common symptom indicating the presence of gallstones (cholelcystoithiais ~ stone in the gallbladder, choledocholithiasis ~ stone in the duct). Gallstone pain is referred to as biliary pain or biliary colic which is a result of obstruction of the bile duct, or less frequently, of the gallbladder itself.
Gallstone pain becomes evident when the stone lodges in the duct, either the gallbladder duct (cystic duct) or the common bile duct. The gallstone(s) may pass out of the duct and the pain may resolve spontaneously. It is complicated by in inflammation of the duct(s) known as cholangitis. Gallstone pain may also be a result of inflammation of the gallbladder (cholecystitis), which is another complication that may occur in conjunction with cholangitis or cholecystitis may occur on its own. Infection, particularly a bacterial infection, may cause or complicate a case of gallstones, cholangitis and cholecystitis.
Other complications associated with gallstones and gallbladder disease may also be a result of gallstone pain. This includes :
- Empyema – collection of pus in the gallbladder
- Hydrops, or mucocele – collection of fluid (water or mucus) causing distension of the gallbladder
Other complications are discussed below and include acute pancreatitis, intestinal obstruction, fistula or perforation.
Most cases of gallstone pain is felt in the epigastrium (upper middle abdomen) and less frequently it my be experienced more laterally in the right upper quadrant (right hypochondrium, right lumbar/flank). Gallstone pain may refer to the tip of the right scapula, back, left upper quadrant (gastric pain) or chest. It is not uncommon for gallstone pain to be mistaken for peptic ulcers, gastritis or myocardial infarction (heart attack).
Gallstone pain comes on suddenly and is very intense. It is described as excruciating and constant and may persist for anywhere between 30 minutes to 2 hours. In some cases, gallstone pain may persist for up to 5 hours. If it is persisting for 6 hours or more then cholecystitis or pancreatitis should be suspected.
Distension of the abdomen may also be noticed with gallstone pain. The gallbladder may be tender but it usually not palpable. A mass in the right upper quadrant (RUQ) mat be due to the omentum (part of the peritoneum) or bowel which becomes inflamed.
This is usually indicative of acute cholecystitis which is commonly due to gallstones. Two fingers (sometimes the entire hand) are used to apply pressure on the right upper quadrant. The patient is asked to breathe in. If this elicits pain leading to the patient to stop breathing in, then this is a positive Murphy’s sign. This can only be confirmed if the same technique does not elicit pain or discomfort in the left upper quadrant.
Other Signs and Symptoms of Gallstones
- Obstructive jaundice is a result of obstruction of the common bile duct or in the cystic duct resulting in stricturing of the hepatic/common bile duct (Mirizzi’s syndrome)
- It results in yellowish discoloration of the skin, sclera (“whites” of the eye), mouth and deeper tissues.
- Pale or clay colored stools and dark urine may also be present.
- Pruritis – itching of the skin
- If the gallbladder is palpable and painless and the patient is jaundiced, then pancreatic or gallbladder cancer should be suspected (Courvoisier’s law).
- The fever is usually low-grade or mild or occasionally high.
- Rigors with fever are not usually present, however, if it does occur along with a abdominal pain, ascending cholangitis should be suspected (Charcot’s triad).
- Nausea and vomiting
- Nausea accompanies the pain and is more frequent after eating food, not only fatty foods.
- It should not be confused with indigestion and other gastrointestinal causes of nausea and vomiting. No belching or bloating (sensation of fullness) is present in gallstones in contrast to gastrointestinal causes.
- Symptoms of acute pancreatitis
- Inflammation of the pancreas due to gallstones (gallstone pancreatitis) may occur as a result of the passing gallstone causing swelling of the ampulla of Vater.
- The stone may have already passed into the duodenum yet the symptoms of acute pancreatitis may persist.
- The signs and symptoms of acute pancreatitis may be very similar to a gallstone attack. Sweating, a rapid pulse and pain radiating to the back which is partly relieved by bending forward is typical of acute pancreatitis.
- Symptoms of intestinal obstruction
- Rarely, a large gallbladder stone may erode the gallbladder and enter the intestine where it causes intestinal obstruction.
- This is known as a gallstone ileus.
- It may result in prominent vomiting, constipation and ascites (swollen stomach) along with severe abdominal pain.
- A fistula or perforation of the gallbladder may also arise in complicated gallbladder disease resulting in the signs and symptom associated with these conditions.