Symptoms of Gallstones
The classic symptom of gallstones is episodic upper abdominal pain characterized by severe, steady pain in the epigastrium and/or right upper quadrant that comes on suddenly, often awakens patients from sleep, may radiate to the upper back, is associated with nausea, and lasts for hours up to a day. 1
Primary Symptoms
Biliary colic (the hallmark symptom):
- Severe, steady pain (not colicky despite the name)
- Located in epigastrium and/or right upper quadrant
- Sudden onset, often at night
- Duration: 1-5 hours (can last up to 24 hours)
- May radiate to the upper back
- Often accompanied by nausea or vomiting 1, 2
- Not typically relieved by position changes, household remedies, or gas passage 3
- Not typically induced by fatty meals (contrary to popular belief) 2
Acute cholecystitis (inflammation of the gallbladder):
- Persistent right upper quadrant pain
- Fever
- Elevated white blood cell count
- Positive Murphy's sign (pain on inspiration when pressing on the right upper quadrant) 4
Complications of Gallstones
Gallstone-related complications occur at a rate of less than 1% annually in asymptomatic patients but at approximately 2% annually in those with symptomatic gallstones 1. These complications include:
- Acute cholecystitis - inflammation of the gallbladder
- Acute pancreatitis - inflammation of the pancreas
- Ascending cholangitis - infection of the bile ducts
- Common bile duct obstruction - causing jaundice
- Gallbladder cancer - more common in patients with large stones 1, 5
Less common complications include:
- Mirizzi syndrome - compression of the common bile duct by a stone impacted in the gallbladder neck
- Cholecystocholedochal fistula - abnormal connection between gallbladder and bile duct
- Gallstone ileus - small bowel obstruction from a gallstone 5
Important Distinctions in Symptomatology
It's crucial to distinguish true gallstone symptoms from unrelated digestive complaints that are often mistakenly attributed to gallstones:
- Not attributable to gallstones (and often persist after cholecystectomy):
Risk Factors for Symptomatic Gallstones
The best predictors of future biliary pain are:
- History of pain at time of diagnosis
- Female sex
- Possibly obesity 1
Risk factors for specific complications:
- Large solitary stones - greater risk of acute cholecystitis
- Multiple small stones - greater risk of biliary pancreatitis
- Large stones of any number - greater risk of gallbladder cancer 1
Diagnostic Considerations
When gallstones are suspected based on symptoms:
- Ultrasound is the first-line imaging modality (sensitivity 81-88%, specificity 80-83%) 4
- If ultrasound is equivocal but clinical suspicion remains high:
Clinical Pearls and Pitfalls
- Many patients with gallstones (up to 80%) are asymptomatic and remain unaware of their presence 3, 6
- Asymptomatic patients have a 2-5% annual risk of developing biliary pain in the initial years of follow-up 1
- The first episode of biliary pain can be mistaken for a heart attack or other abdominal catastrophe 3
- Persistent dyspeptic symptoms frequently occur following cholecystectomy, especially in patients with a prolonged history of such symptoms prior to surgery 1
- Not all right upper quadrant pain is due to gallstones - other causes include liver disease, peptic ulcer disease, and referred pain from the chest or spine 4
Understanding the true symptoms of gallstones is essential for accurate diagnosis and appropriate treatment decisions, as removing the gallbladder will only relieve symptoms that are truly caused by gallstones.