What are the symptoms of a gallbladder attack?

Symptoms of a Gallbladder Attack

A gallbladder attack presents with severe, steady right upper quadrant or epigastric pain lasting 30 minutes to several hours, often radiating to the upper back, typically occurring at night, and frequently accompanied by nausea. 1, 2

Primary Pain Characteristics

The pain pattern follows a distinctive presentation:

• Location: Pain occurs in the right upper quadrant and/or epigastrium in all patients, with maximal intensity under the costal arch (51%) or in the epigastrium (41%). 2, 3
• Radiation: Pain radiates to the upper back or right infrascapular area in approximately 63% of patients. 2, 3
• Onset: Pain begins relatively abruptly, often awakening patients from sleep, with 77% of attacks occurring in the late evening or at night. 4, 3
• Duration: Episodes typically last from 30 minutes to several hours, with 85% lasting more than one hour and almost never less than 30 minutes. 2, 3
• Quality: The pain is steady in intensity rather than cramping or colicky, with a characteristic pattern of incipient warning pain building to a relatively steady state before subsiding. 4, 3
• Severity: Pain intensity is very high, with mean visual analogue scale scores of 90 mm on a 0-100 scale. 3

Associated Symptoms

Beyond the characteristic pain, patients commonly experience:

• Nausea and vomiting: Frequently reported during attacks. 4, 5
• Anorexia: Loss of appetite is common during symptomatic episodes. 2
• Urge to move: Approximately 71% of patients experience an urge to walk around during attacks. 3
• Fever: May be present, particularly when significant inflammation (acute cholecystitis) develops. 1, 2

Physical Examination Findings

Murphy's sign is a key clinical finding:

• Focal tenderness over the gallbladder during palpation, elicited by asking the patient to take a deep breath while the examiner palpates the right upper quadrant. 1, 5
• Can also be elicited during ultrasound examination (sonographic Murphy's sign), though this has relatively low specificity. 1, 2
• Abdominal tenderness in the right upper quadrant is characteristic. 1
• A palpable gallbladder lump suggests complicated acute cholecystitis. 1

Timing and Meal Relationship

• Pain typically occurs more than 1 hour after meals rather than immediately postprandially. 6
• The delayed onset helps distinguish gallbladder attacks from other gastrointestinal conditions. 6

Associated Dyspeptic Symptoms

Important caveat: While many patients with gallstones report dyspeptic symptoms (indigestion, belching, bloating, heartburn), these are probably unrelated to the stones themselves and frequently persist after cholecystectomy. 4 Food intolerance, particularly to fatty foods, is reported by 66% of patients, though only 48% specifically report fatty food intolerance. 3

Red Flags for Complications

Be alert for signs suggesting complicated cholecystitis or other serious pathology:

• Persistent fever and elevated white blood cell count suggest acute cholecystitis. 1
• Pericholecystic fluid on imaging indicates inflammation. 1
• Jaundice or significantly elevated liver enzymes suggest common bile duct stones or cholangitis. 1
• Patients with ongoing signs of infection beyond initial presentation warrant urgent diagnostic investigation. 1

Clinical Pitfall

Lower abdominal pain is uncommon in gallbladder disease (only 12.3% of gallstone patients versus 29.9% of controls), so its presence should prompt consideration of alternative diagnoses. 6