Can gallstones cause back pain?

Can Gallstones Cause Back Pain?

Yes, gallstones commonly cause back pain—specifically, pain that radiates from the right upper quadrant or epigastrium to the upper back, occurring in approximately 59-63% of patients with gallstone disease. 1, 2, 3

Characteristic Pain Pattern of Gallstone Disease

Primary Pain Location and Radiation

• All patients with symptomatic gallstone disease experience pain in the right upper quadrant (RUQ) including the upper midline epigastrium. 3
• Back radiation is a cardinal feature, occurring in 59-63% of patients with gallstones. 2, 3
• The pain typically radiates to the upper back, with maximal pain located under the costal arch (51%) or in the epigastrium (41%), but can also be felt in the back itself (5% report maximal pain in the back). 3
• For choledocholithiasis (common bile duct stones) specifically, the characteristic pattern is constant epigastric pain radiating to the back. 2

Pain Characteristics That Distinguish Gallstone Disease

• The pain is severe (mean VAS score of 90/100), steady in intensity, and lasts for hours—typically more than one hour and up to a day. 1, 3
• Pain onset is relatively abrupt, often awakening patients from sleep, with 77% of attacks occurring in the late evening or at night. 1, 3
• The pain follows a characteristic pattern: incipient or low-grade warning pain with a subsequent relatively steady state until subsiding (present in 90% of patients). 3
• An urge to walk around during pain attacks is experienced by 71% of patients. 3

Associated Symptoms

• Nausea occurs in 69% of patients and vomiting in 31%, making these common but not universal features. 2, 3
• Functional indigestion symptoms (gastroesophageal reflux, dyspepsia) are seen in the vast majority of patients in association with attacks. 3

Clinical Pitfalls and Important Caveats

Atypical Presentations

• While back pain is common, it is not universal—approximately 37-41% of patients do not experience back radiation. 2, 3
• Some patients may have maximal pain behind the sternum (3%), which can mimic cardiac disease. 3
• Many persons with gallstones have no history of pain attacks at all, and dyspeptic symptoms (indigestion, belching, bloating) are probably unrelated to the stones themselves and frequently persist after surgery. 1

Diagnostic Approach

• Ultrasound is the first-line imaging modality for suspected gallstone disease, with 96% accuracy for detecting gallstones. 4, 5
• The diagnosis of gallstone-related pain is primarily based on clinical criteria, with imaging serving to confirm the presence of stones. 6
• Pain characteristics alone cannot definitively establish gallstones as the cause—imaging confirmation is essential before attributing symptoms to gallstones. 4

Risk Stratification

• Patients with symptomatic stones at discovery have approximately 6-10% annual recurrence of symptoms and 2% risk of biliary complications. 1
• The best predictors of future biliary pain are a history of pain at diagnosis, female gender, and possibly obesity. 1