Can biliary issues cause pain in the upper middle abdomen?

Biliary Pain Location

Yes, biliary issues commonly cause pain in the upper middle abdomen (epigastrium), though right upper quadrant pain is the classic presentation. 1

Typical Pain Patterns in Biliary Disease

Biliary colic characteristically presents with severe pain located in both the epigastrium AND/OR the right upper quadrant. 2, 3 The pain pattern includes:

• Epigastric location is explicitly recognized as a typical presentation of gallstone-related pain, not an atypical one 2, 3
• Pain may be isolated to the epigastrium alone or may involve both epigastric and right upper quadrant regions simultaneously 2, 3
• The pain typically radiates to the upper back or right shoulder 2, 3
• Onset is relatively abrupt, often awakening patients from sleep 3
• Pain is steady in intensity (not cramping), lasts for hours up to a day, and is associated with nausea 3

Clinical Context

Most patients with acute cholecystitis experience right upper quadrant abdominal pain, but epigastric pain is a well-recognized presentation pattern. 1 The American College of Radiology guidelines acknowledge that:

• Acute cholecystitis is the most frequent complication of gallstone disease and may be life-threatening 1
• Clinical history and physical examination alone cannot reliably predict presence or absence of acute cholecystitis 1
• Imaging studies play a major role in establishing diagnosis when biliary disease is suspected 1

Diagnostic Approach for Upper Middle Abdominal Pain

Right upper quadrant ultrasound remains the first-line imaging study even when pain is primarily epigastric, as long as biliary disease is in the differential diagnosis. 1, 4 The diagnostic algorithm includes:

• Ultrasound is rated 9/9 (usually appropriate) by the American College of Radiology for evaluating suspected biliary disease regardless of whether pain is epigastric or right upper quadrant 4, 5
• Ultrasound detects gallstones with 96% accuracy and can identify gallbladder wall thickening, pericholecystic fluid, and bile duct abnormalities 1, 4
• If ultrasound is negative or equivocal but clinical suspicion remains high, MRCP is the preferred next step with 85-100% sensitivity for detecting choledocholithiasis 4

Important Clinical Pitfalls

Do not dismiss biliary disease simply because pain is epigastric rather than right upper quadrant. 2, 3 Common mistakes include:

• Assuming epigastric pain excludes biliary pathology—this is incorrect as epigastric location is explicitly described as characteristic of biliary colic 2, 3
• The sonographic Murphy sign has relatively low specificity and is unreliable if the patient received pain medication prior to imaging 1, 4
• Over one-third of patients initially thought to have acute cholecystitis actually have RUQ pain from other causes, so maintain a broad differential 6