Biliary Pain: The Pain Associated with Gallbladder Disease
The pain associated with the gallbladder is called biliary pain or biliary colic, despite the term "colic" being somewhat misleading as the pain typically does not fluctuate but remains steady 1.
Characteristics of Biliary Pain
Biliary pain has specific characteristics that help distinguish it from other types of abdominal pain:
- Location: Primarily in the epigastrium and/or right upper quadrant of the abdomen 2, 3
- Radiation: May radiate to the right shoulder or upper back 1, 4
- Onset: Abrupt onset, often awakening patients from sleep 4
- Duration: Episodes typically last at least 30 minutes, often persisting for 2-4 hours 2, 1
- Pattern: Pain builds to a steady level rather than fluctuating 1
- Severity: Severe enough to interrupt activities or lead to medical attention 1
- Relief factors: Not relieved by bowel movements, postural changes, or antacids 1
Associated Symptoms
Biliary pain may be accompanied by:
- Nausea and vomiting 1
- Sleep disruption 1
- In some cases, fever and elevated white blood cell count may indicate complications such as acute cholecystitis 1
Pathophysiology of Biliary Pain
Biliary pain is thought to occur due to:
- Increased gallbladder pressure caused by abnormal gallbladder contractions 1
- Structural or functional outflow obstruction 1
- Two main mechanisms have been proposed 1:
- Hypokinesia: Impaired gallbladder contractility (hypomotility)
- Dyskinesia: Partial obstruction (structural or functional) distal to the gallbladder
Diagnostic Criteria
The Rome III criteria provide standardized diagnostic criteria for functional gallbladder disorder, which presents with biliary pain 1:
- Episodes of pain in the right upper quadrant and/or epigastrium with all of the following:
- Episodes last at least 30 minutes
- Recurrent episodes occur at different intervals (not daily)
- Pain builds to a steady level
- Pain is severe enough to interrupt activities or require medical attention
- Pain is not relieved by bowel movements, postural changes, or antacids
- Other structural diseases have been excluded
- Gallbladder is present
- Normal liver tests and pancreatic enzymes
Common Pitfalls in Diagnosis
Several important caveats should be noted:
- Biliary pain is often misdiagnosed due to its epigastric location, which can be confused with cardiac pain or other gastrointestinal conditions 2
- The term "biliary colic" is misleading as the pain typically does not fluctuate like true colic 2
- Dyspeptic symptoms (indigestion, belching, bloating, food intolerance) are common in people with gallstones but may be unrelated to the stones themselves 4
- Not all gallstones cause symptoms—only about 20% of patients with gallstones are symptomatic 2
- Careful correlation between imaging findings of gallstones and the patient's symptoms is essential to avoid misdiagnosis 2
Management Considerations
For acute biliary pain:
- NSAIDs are effective for pain relief in biliary colic 5
- Laparoscopic cholecystectomy is the standard treatment for symptomatic gallstone disease 3
- For patients with functional biliary pain without gallstones, cholecystokinin-cholescintigraphy may help diagnose gallbladder dyskinesia 1, 6
Understanding the specific characteristics of biliary pain is crucial for accurate diagnosis and appropriate management of gallbladder disease.