What are the symptoms of gallstones?

Symptoms of Gallstones

Most patients with gallstones (approximately 80%) remain completely asymptomatic throughout their lives, but when symptomatic, gallstone disease characteristically presents as severe, steady right upper quadrant or epigastric pain that radiates to the upper back, lasts more than one hour, occurs predominantly at night, and is accompanied by nausea. 1

Asymptomatic Gallstones

• The majority of gallstones (nearly 80%) are discovered incidentally during imaging for other reasons and never cause symptoms. 1, 2
• Asymptomatic patients with gallstones have only a 2-5% annual incidence of developing biliary pain during initial years of follow-up. 3
• Gallstone-related complications occur at a rate of less than 1% annually in asymptomatic patients. 3

Symptomatic Gallstone Disease: Biliary Colic

Primary Pain Characteristics

When gallstones become symptomatic, the hallmark presentation is biliary colic with very specific features:

• Severe, steady pain located in the right upper quadrant and/or epigastrium that is unaffected by position changes, antacids, or gas passage. 1, 4
• The pain is characteristically very intense, with mean visual analogue scale scores of 90 mm on a 0-100 scale. 5
• Pain radiates to the upper back or right infrascapular area in 63% of patients. 5, 6
• The pain follows a characteristic pattern with incipient or low-grade warning pain, followed by a relatively steady state until subsiding in 90% of patients. 5

Temporal Pattern

• Pain attacks occur predominantly in the late evening or at night (77% of cases). 5
• Duration is typically more than one hour (85% of attacks), and almost never less than 30 minutes. 5
• The onset is relatively abrupt and often awakens patients from sleep. 3

Associated Symptoms

• Nausea is common and occurs in 38-48% of patients. 7
• Vomiting accompanies the pain in many cases. 8
• Anorexia (loss of appetite) is common during symptomatic episodes. 8, 7
• An urge to walk around is experienced by 71% of patients during attacks. 5
• Fever may be present but is not a defining feature of uncomplicated biliary colic; when present, it suggests acute cholecystitis. 8

Food Intolerance

• 66% of patients report intolerance to at least one kind of food, though only 48% specifically to fatty foods. 5
• Intolerance to fried or fatty food combined with right upper quadrant pain is significantly associated with gallstones. 6

Acute Cholecystitis (Complicated Gallstone Disease)

When gallstones cause acute cholecystitis, the symptom complex expands:

• Right upper quadrant abdominal pain, nausea, vomiting, anorexia, and fever are the classic tetrad. 8
• Murphy's sign (focal tenderness over the gallbladder during palpation) is present in 43-48% of cases with a specificity of 0.79. 7
• Abdominal tenderness is reported in 64.7% of patients. 7
• Fever >38°C occurs in only 6.4-10% of cases. 7

Chronic Cholecystitis

• Recurrent episodes of right upper quadrant or epigastric pain lasting more than one hour, occurring predominantly at night. 7
• Associated with gallstones in 95% of cases. 7
• Pain radiates to the upper back or right infrascapular area in 63% of patients. 7

Important Clinical Distinctions

Symptoms NOT Attributable to Gallstones

A critical pitfall is attributing non-specific dyspeptic symptoms to gallstones:

• Indigestion, belching, bloating, abdominal discomfort, heartburn, and specific food intolerance are common in persons with gallstones but are probably unrelated to the stones themselves and frequently persist after cholecystectomy. 3
• Chronic, persistent back pain present uniformly, and pain that frequently comes and goes and lasts less than 15 minutes, are not attributable to gallstone disease. 4
• These non-specific symptoms should not be used as indications for cholecystectomy as they are unlikely to resolve with surgery. 4

Predictors of Future Symptoms

• The best predictors of future biliary pain are a history of pain at the time of diagnosis, female gender, and possibly obesity. 3
• Patients whose stones are symptomatic at discovery have a more severe course, with approximately 6-10% suffering recurrent symptoms each year and 2% developing biliary complications. 3

Diagnostic Approach

• Ultrasound is the first-line imaging modality with 96% accuracy for gallstone detection. 8, 1, 4
• The sonographic Murphy sign (focal tenderness over the gallbladder during ultrasound examination) can help differentiate acute cholecystitis from uncomplicated gallstones. 4
• However, the absence of a sonographic Murphy sign is unreliable as a negative predictor if the patient has received pain medication prior to imaging. 4

Critical Complications to Recognize

Gallstones can lead to life-threatening complications that require urgent recognition:

• Acute cholecystitis (inflammation of the gallbladder). 8
• Choledocholithiasis (stones in the common bile duct causing biliary colic, jaundice, and potentially serious complications). 1
• Acute cholangitis (infection of the bile ducts). 2
• Biliary pancreatitis. 9, 2