What are the signs and symptoms of gallbladder disease?

Signs and Symptoms of Gallbladder Disease

The primary signs and symptoms of gallbladder disease include right upper quadrant abdominal pain, positive Murphy's sign, fever, and abdominal tenderness, with pain typically being severe, steady in intensity, and often occurring at night. 1, 2

Cardinal Symptoms of Gallbladder Disease

Pain Characteristics

• Location: Right upper quadrant and/or epigastrium (66% have pain distributed across both areas) 3
• Quality: Severe, steady intensity (mean VAS score of 90/100) 3
• Radiation: Often radiates to the upper back (63% of patients) 3
• Timing: Predominantly occurs in late evening or at night (77% of cases) 3
• Duration: Typically lasts more than one hour (85% of attacks), almost never less than 30 minutes 3
• Pattern: 90% of patients experience a characteristic pattern of warning pain that builds, reaches a steady state, then gradually subsides 3

Associated Symptoms

• Fever (indicative of inflammation/infection) 1, 4
• Nausea and vomiting (present in approximately 60% of cases) 4, 5
• Urge to walk around during pain episodes (71% of patients) 3
• Jaundice (in cases involving common bile duct obstruction) 2

Physical Examination Findings

• Murphy's sign: Pain on deep palpation below the right costal margin during inspiration (highly specific for acute cholecystitis) 1, 2
• Abdominal tenderness in right upper quadrant 1, 4
• Palpable gallbladder lump (sign of complicated acute cholecystitis) 1
• Fever (indicative of inflammation/infection) 1, 4

Symptom Variations by Type of Gallbladder Disease

Acute Cholecystitis

• Acute right upper quadrant pain
• Fever
• Nausea and vomiting
• Positive Murphy's sign
• Leukocytosis 4

Biliary Colic (Uncomplicated Gallstone Disease)

• Episodic upper abdominal pain
• Abrupt onset, often awakening patients from sleep
• Steady intensity pain lasting hours to a day
• May be associated with food intolerance (66% of patients report food intolerance, but only 48% specifically to fatty foods) 6, 3

Complicated Gallstone Disease (Choledocholithiasis, Cholangitis)

• Jaundice
• Fever with chills (especially in cholangitis)
• Right upper quadrant pain
• Nausea and vomiting 7

Associated Digestive Symptoms

• Dyspeptic symptoms are common in gallstone patients 6, 3:
  • Indigestion
  • Belching
  • Bloating
  • Abdominal discomfort
  • Heartburn
  • Food intolerance

It's important to note that these dyspeptic symptoms often persist after cholecystectomy, suggesting they may not be directly related to the gallstones themselves 6.

Diagnostic Considerations

When gallbladder disease is suspected based on symptoms:

1. Laboratory tests should include:

   • Liver function tests (bilirubin, AST, ALT, ALP, GGT)
   • Inflammatory markers (CRP, PCT in critically ill patients)
   • Complete blood count (leukocytosis) 1, 4

2. Imaging studies:

   • Ultrasound is the first-line imaging modality (sensitivity 81-88%, specificity 80-83%) 2
   • HIDA scan is the gold standard for diagnosing acute cholecystitis when ultrasound is inconclusive 2, 4
   • CT with IV contrast may be used to detect complications or alternative diagnoses 1, 2
   • MRCP for suspected common bile duct stones 1, 2

Clinical Pitfalls and Caveats

• Atypical presentations are common in elderly patients, who may present without fever or pain 2
• Acalculous cholecystitis (5-10% of cases) occurs without gallstones, typically in critically ill patients 4
• Persistent dyspeptic symptoms after cholecystectomy are common and may indicate that these symptoms were not related to gallstones 6
• Absence of a positive Murphy's sign does not rule out gallbladder disease 2
• Early diagnosis is crucial to prevent potentially life-threatening complications such as cholangitis, pancreatitis, or gallbladder perforation 2