Can a 25 mm cholelithiasis (gallstone) cause pain in the epigastrium?

Can a 25 mm Cholelithiasis Cause Pain in the Epigastrium?

Yes, a 25 mm gallstone can definitely cause epigastric pain, as gallstone-related pain commonly presents in the epigastrium and/or right upper quadrant, particularly when the stone is large enough to cause obstruction or inflammation. 1, 2

Gallstone Pain Characteristics and Presentation

• Gallstones typically cause episodic upper abdominal pain that is severe, steady in intensity, and located in the epigastrium and/or right upper quadrant 1
• The pain onset is relatively abrupt, often awakening patients from sleep, and can last for hours up to a day 1
• Pain may radiate to the upper back and be associated with nausea 1
• The classic presentation of symptomatic cholelithiasis includes right upper quadrant pain, but epigastric pain is a common manifestation as noted in clinical guidelines 2

Size Considerations and Symptom Correlation

• Large stones (>10-15 mm), such as a 25 mm stone, are more likely to cause symptoms and complications, particularly if they become impacted 2
• Large solitary stones carry a higher risk of acute cholecystitis compared to smaller stones 1
• Stones ≥25 mm are considered very large and are more likely to cause mechanical obstruction, leading to pain 2
• Even asymptomatic gallstones larger than 2-3 cm warrant consideration for intervention due to increased risk of complications 2

Pathophysiological Mechanisms

• Pain occurs when a gallstone obstructs the cystic duct or neck of the gallbladder, causing distension and inflammation 2
• A 25 mm stone can cause partial or complete biliary obstruction, leading to epigastric pain that mimics chronic cholecystitis 2
• Large stones may erode into surrounding structures, potentially causing Mirizzi syndrome or cholecystocholedochal fistula, both of which can present with epigastric pain 3
• Inflammation from gallstone disease can irritate the diaphragm, causing referred pain to the epigastric region 4

Diagnostic Considerations

• Ultrasonography is the gold standard for diagnosing gallstones, with nearly 98% sensitivity for detecting cholelithiasis 2, 4
• CT imaging may show gallbladder wall thickening, pericholecystic inflammation, and other signs of gallstone complications that can cause epigastric pain 2
• MRCP (Magnetic Resonance Cholangiopancreatography) is highly accurate for identifying gallstones and associated biliary complications that may present with epigastric pain 2
• Laboratory tests including liver enzymes and bilirubin should be performed to assess for complications of gallstone disease that may cause epigastric pain 2

Clinical Pitfalls and Caveats

• Epigastric pain from gallstones may be mistaken for other conditions such as peptic ulcer disease, gastritis, or pancreatitis 2
• Dyspeptic symptoms (indigestion, belching, bloating) are common in persons with gallstones but may be unrelated to the stones themselves 1
• Not all gallstones cause symptoms—approximately 50-70% of people with gallstones are asymptomatic at diagnosis 5
• The absence of right upper quadrant tenderness does not rule out symptomatic gallstone disease, as epigastric pain may be the predominant or only symptom 4
• Even in elderly patients, common bile duct stones can present with epigastric pain rather than typical right upper quadrant pain 2

In conclusion, a 25 mm gallstone is certainly large enough to cause epigastric pain through various mechanisms including obstruction, inflammation, and referred pain patterns. When evaluating a patient with epigastric pain, cholelithiasis should be considered in the differential diagnosis, especially with a known gallstone of this size.