Symptoms of Gallstones

Typical symptoms of gallstones are of three types: 

• Pain between the breast bone and the belly button (epigastric) pain or discomfort
• Pain beneath the breastbone (substernal), which may seem like a heart attack
• Pain in the right upper quadrant, which may shoot to the right side of the back or up to the right shoulder

These pains, which are referred to as biliary colic, may be mild or severe, sharp or crampy, and may last from minutes to hours.  They typically occur a few hours after eating and most commonly at night or early morning.  They frequently wake the patient from sleep.  The pain may be associated with nausea and vomiting.  It is often associated with bloating.  In fact, bloating and fullness are common symptoms that may be related to gallstones and unassociated with pain. 

However, bloating and fullness may occur for other reasons.  If that is the case, treatment of the gallstones will not lead to relief of the symptoms.  In fact, the only reliable symptoms of gallbladder disease, which will almost always be eliminated by removing the gallbladder, are the three pain syndromes noted above.

Gallstone Q&A

Do the pain and symptoms occur in all patients with gallstones?

No.  There are over 20 million Americans with gallstones but only about 750,000 gallbladders removed per year.  In addition, about 1 million new cases will be diagnosed each year.  Therefore, most patients with gallstones have no symptoms or symptoms so mild they do not affect their lifestyle.  It is estimated that only 20% of people with gallstones and no symptoms will develop symptoms during the next twenty years of their life.  However, people who do have symptoms are likely to continue to have symptoms.  Furthermore, in a large percentage of symptomatic patients, the frequency and severity of the attacks increase over time.

Why do these symptoms occur?

After we eat there are chemical (hormonal) and nerve signals from our intestinal tract (duodenum) which cause the gallbladder to contract.  When there are no stones present, the gallbladder empties its bile freely.  However, when stones are present, the stones can block the exit of the gallbladder at the cystic duct.  This leads to secretion of water into the gallbladder to relieve the obstruction by increasing the force of contraction. However, because the exit is blocked, this leads to distention (swelling) of the gallbladder, which in turn causes the epigastric and or substernal pain.  

Continued distention of the gallbladder leads to reduced blood flow to the wall of the gallbladder and to inflammation.  This is associated with pain in the right side of the upper abdomen. The nausea, vomiting and bloating are a non-specific intestinal response (visceral response) to these insults.  

Usually after a period of time, the stone will fall out, bile will exit, the distention is relieved and the pain goes away.  However, if there was a lot of inflammation, some residual discomfort may remain for hours to days.  The length of time this residual pain is present is related to the severity of the attack.  Occasionally, the stone gets firmly stuck and does not fall back into the gallbladder.  This leads to continued inflammation and pain known as acute cholecystitis.  This situation is similar to acute appendicitis although the gallbladder is not as likely to rupture as the appendix is.  Typically, patients with acute cholecystitis have large gallstones.  They are much sicker than patients with biliary colic, frequently have a fever and need emergency or urgent surgery.

What are my chances of more symptoms?

The National Cooperative Gallstone Study was performed in the early 1980's to evaluate this question as well as other.  The results of these studies revealed that 70% of patients with previous symptoms had at least one more episode of pain during a two year period if the gallstones were not treated.  Furthermore, approximately 50% had severe attacks and 20% had more than one attack.  Therefore, you can expect attacks in the future if you have had them in the past.  The question is when they will occur.  Unfortunately, they often will occur when you least want them, Murphy's Law.

Is the size or number of the stones related to whether or not patients have symptoms?

No.  Patients may have one small stone and have severe and repetitive symptoms while others with multiple large stones may have none.  However, it is important to note that the type of symptoms and complications of gallstone disease are related to the size of the stones.  For example, patients with gallstones greater than one centimeter in size are more likely to get acute cholecystitis than those with gallstones less than one centimeter in size.  Patients with gallstones greater than 3 centimeters in diameter are more likely to get  gallbladder cancer than those with stones smaller than 3 centimeters or no stones. (Nonetheless, gallbladder cancer is so rare it is not a problem worth worrying about.)  Patients, on the other hand, with small, less than 1/2 centimeter stones are more likely to get passage of the stones through the cystic duct into the common duct.  This can lead to two severe and life threatening problems: pancreatitis and obstructive jaundice.

• Pancreatitis is a chemical inflammation of the pancreas, the organ that makes insulin and digestive enzymes that break up food in our intestinal tract.  It results from the passage of a stone down the common duct and out the end of the common duct into the intestine.  As the stone passes through, it can block the exit of the duct from the pancreas which also empties into the common duct or the intestine near the common duct.  Because the pancreatic duct contains digestive enzymes that breakdown food, the blockage can lead to digestion of the pancreas itself. As a result, patients with acute pancreatitis can develop severe complications and death.  Acute pancreatitis is usually associated with severe pain in the epigastrium that radiates straight back, is worse lying down and better sitting up.  It is associated with vomiting and retching.
• Obstructive jaundice from stones (choledocholithiasis) is the condition whereby stones enter and block the flow of bile in the common duct from the liver to the duodenum.  This results in a back up of bile which causes the liver to not work correctly, fats to be malabsorbed, the eyes and skin to turn yellow, the urine to turn tea colored and the stool to turn clay colored.  Because the bile becomes stagnant in the common bile duct, the risk of infection is great and can be life threatening.  It is usually associated with severe pain in the epigastrium.

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