Gallbladder Pain: Classification, Types, Pathophysiology, Signs, Symptoms, Treatment, Diagnosis

The gallbladder is a little hollow organ, a sac like structure that is situated beneath the liver. It helps in storage of the bile. The bile helps in digestion of the foods, especially fatty foods. Usually the gallbladder doesn’t cause any problems, but if the flow of bile from gallbladder gets blocked or slowed down then a variety of problems can occur resulting in gallbladder pain or gallbladder disease. Gallbladder pain is most commonly caused by 2 reasons, existence of stones in gallbladder i.e. gallstones or cholelithiasis, and the inflammation of gallbladder i.e. cholecystitis. Gallstones vary in size from 1 to 2 mm to several centimeters and are made up of cholesterol or pigment. Formation of gallstones leads to cholecystitis or inflammation of gallbladder causing severe gallbladder pain. Other than this there may be other causes for gallbladder pain like biliary colic and/or dysfunctional gallbladder or cholecystitis. The pain of biliary colic remains constant; however, it can fluctuate in intensity and disappear gradually. The pain usually lasts for 20 minutes to several hours.

If pain is shorter than 20 minutes, it is unlikely to be caused by gallstones. If pain lasts longer than several hours it means that the gallstone causing the biliary colic has led to a complication, like inflammation of gallbladder (cholecystitis).

The gallbladder pain is commonly located in the epigastrium. Movement does not have any effect on the gallbladder pain, as movement has no effect on the distended ducts or gallbladder. The next most common location of gallbladder pain is the right upper abdomen area where the gallbladder is located. Other less common location of gallbladder pain is the left upper abdomen and rarely the lower abdomen. Sometimes the gallbladder pain may radiate to other areas like the right shoulder or the tip of the right scapula. Biliary colic tends to occur more in the evening time or at night, often disrupting the patient’s sleep.

• Gallbladder Pain Caused Due to Gallstones (Cholelithiasis): In this condition the gallbladder develops stones inside it. The gallstones may be large or small and they cause gallbladder pain known as biliary colic. However 90% of people having gallstones have no symptoms and these stones are accidentally discovered during tests for other conditions like while doing abdominal ultrasound.
• Gallbladder Pain Caused Due to Biliary Colic: When gallstones block cystic duct it leads to severe, spasmodic type of pain known as biliary colic. The gallbladder contracts vigorously against the blockage and causes severe pain. Biliary colic episodes usually last only an hour or two and may recur infrequently.
• Gallbladder Pain Caused Due to Inflamed Gallbladder (Cholecystitis): Gallstones are most common cause for inflammation of gallbladder. Other causes include excessive alcohol use, infections, or even tumors that cause bile buildup. In cholecystitis, gallbladder walls become inflamed, swollen and painful. The episodes of inflammation can last for several hours or even a few days. Fever may also be present. Usually about 20% of the time, the inflamed gallbladder is invaded by intestinal bacteria and becomes infected. Occasionally, the gallbladder may rupture, which is a surgical emergency. Gallbladder pain caused due to cholecystitis with fever is a serious condition and requires medical attention immediately.
• Gallbladder Pain Caused Due to Dysfunctional Gallbladder or Cholecystitis: Repeated episodes of cholecystitis leads to dysfunctional gallbladder or cholecystitis. In this condition the gallbladder becomes rigid and scarred due to prolonged presence of gallstones and repeated episodes of inflammation. Symptoms are vague, but constant such as abdominal fullness, indigestion, and increased gas. Chronic diarrhea is also a common symptom, usually occurring after meals.

Gallstones causing gallbladder pain can develop anywhere in biliary tree, but most common place of formation is in the gallbladder. The following are the types of gallstones: Cholesterol-type, pigment-type, and mixed.

Normally, there is balance in the level of bile acids, cholesterol, and phospholipids. Any change in the balance predisposes the patients to formation of lithogenic bile resulting in development of cholesterol type gallstones.

Pigment type gallstones are formed of calcium bilirubinate and are present in two types, black and brown. Presence of black stone indicates liver disease. The brown stones are generally formed outside gallbladder associated with bacterial infection of biliary tract.

Biliary sludge is formed as a result of bile stasis which eventually leads to gallstone formation. Infection of biliary tree, especially with bacteria like E. coli and parasites increases the risk of development of ductal stones. Intestinal resection is also shown to result in gallstones in some cases. These gallstones are mainly of pigment variety.

Females are at greater risk to get gallstones than men. Oral contraceptives which have high estrogen also increase risk of gallstone formation in females.

When gallstones become lodged in the bile ducts (that lead from gallbladder or liver into intestines), they give rise to a specific type of gallbladder pain called biliary colic. Most of the time, the gallstones do not cause pain and are usually found incidentally during abdominal ultrasonography. When gallstones lodge in cystic duct, common hepatic duct, or CBD this interrupts the normal flow of the bile from the liver and the bile gets accumulated leading to distention of the ducts and the gallbladder resulting in pain or biliary colic. This gallbladder pain is relieved when the stones are dislodged or removed from the duct.

Gallbladder pain can be due to many reasons, stones and inflammation (cholecystitis) being most common reasons. Other causes of gallbladder pain include biliary colic, dysfunctional gallbladder or cholecystitis.

• Women are much more likely than men to develop gallstones, which can cause gallbladder pain because they undergo pregnancy and hormone replacement therapy.
• In children, conditions like spinal cord injury, history of surgery to abdomen, compromised immune system and receiving intravenous nutrition puts them at higher risk for gallstones.
• Hispanic population and Northern European population are at greater risk for gallstones than the Asian and African population. Asian population who do develop gallstones most likely have brown pigment type. North and South Americans, and native populations in Chile and Peru are specially vulnerable to develop gallstones. All native Indian females in Chile and Peru region get gallstones.
• Heredity also plays an important role in increasing risk for developing gallstones.
• People who have diabetes, obesity, weight fluctuations, and who have had bariatric surgery are at increased risk for developing gallbladder pain due to gallstones.
• Other risk factors include: Prolonged intravenous feeding, Crohn’s disease, bone marrow or solid organ transplantation, chronic hemolytic anemia including sickle cell anemia, high consumption of heme iron, cirrhosis and metabolic syndrome.

Symptoms of gallbladder pain vary depending on the type of gallbladder condition the patient has, although most of the symptoms present are similar in the different types of gallbladder problems. More commonly, the gallbladder pain symptoms start with pain in the upper abdominal area, either in the upper right or middle region. Simple gallstones that are not blocking cystic duct do not cause any symptoms. They are usually discovered during an x-ray to diagnose another condition. The most general symptom of gallbladder pain due to biliary colic is nausea with or without vomiting.

• Acute abdominal pain
• Pain that may extend beneath the right shoulder blade or to the back
• Pain that worsens after eating a meal, especially fatty or greasy foods
• Increasing pain with deep breathing
• Sweating
• Weakness
• Lightheadedness
• Shortness of breath.
• Dull, sharp, or crampy pain.
• Tenderness in the right upper quadrant of the abdomen
• Chest pain
• Heartburn, indigestion, and flatulence
• Abdominal bloating or belching
• Nausea and vomiting
• Fever with chills
• Jaundice
• Clay-like light colored stools.

Treatment for gallbladder pain depends on the severity and frequency of gallbladder disease.

• Wait and watch approach.
• Removing stone non-surgically
• Excision of gallbladder.

When a patient has lack of symptoms with gallstones, then wait and watch approach is usually followed. Sometimes exceptions are made to those patients who are vulnerable for complications from these gallstones, such as cancer of gallbladder, and patients with stones measuring more than 4 cm.

Patients having normal investigations and no acute pain or complication with normal laboratory test can be relieved from hospital on oral antibiotic and analgesics.

• Intravenous painkillers are given for acute gallbladder pain. These include Demerol or Toradol. Medication like ketorolac is not given to patients suffering from gallbladder pain who may require surgery. Side effects of these drugs include feeling nauseous, vomiting, as well as drowsiness. Opioid medications like morphine can also be given for gallbladder pain as it has less adverse effects, although some physicians stay away from them in gallbladder conditions.
• Cholecystectomy is another option.
• Patients suffering from gallbladder pain due to gallstones also have the choice of undergoing a stone-breaking technique called lithotripsy. This treatment works the best when there is single stone and it measures less than 3 cm.
• Individuals suffering from gallbladder pain who do not wish to have surgery and/or have medical conditions that increase risk of surgery can carry on with medication therapy. Recurrence rates of gallbladder problems are more with nonsurgical methods but with introducing laparoscopic cholecystectomy nonsurgical approach has come down a great deal. Patients with severe inflammation of gallbladder or CBD stones need to instantly have surgery as this condition can be quite serious and treatment with medications is not recommended.
• Gallbladder pain patients with severe cholecystitis generally require surgery for removal of gallbladder. Laparoscopic cholecystectomy is the procedure of choice these days, as it is less invasive than normal cholecystectomy. In patients with acute cholecystitis, first the inflammation of gallbladder should be reduced. This is done by fasting, IV fluids as well as oxygen, Painkillers like Demerol and
• NSAIDs like ketorolac can also be useful to treat gallbladder pain. IV antibiotics are given if patient shows indications of infection like fever or elevated WBC count. IV antibiotics are also administered in people who don’t have improvement even after 24 hours.
• In patients with obstruction from CBD stones, procedures like ERCP can be performed to confirm and remove the stones. Laparoscopic cholecystectomy is also being done nowadays for diagnosis and removing stones.
• Oral drugs can also be used to break up gallstones. This is called “Oral Dissolution Technique.” In this therapy, bile acids are given in form of pill so as to liquefy gallstones. It can also be used along with lithotripsy, but both are used these days very rarely. The commonly used drugs are Ursodiol, Actigall, and chenodiol. Ursodeoxycholic acid is said to be most common and safe drug. Long-term use of these drugs considerably reduces risk of developing biliary pain as well as cholecystitis; however, since gallstones recur in majority of people, this is not a long term solution.
• Patients who have smaller stones (as little as less than 2 cm) having high cholesterol generally benefit more with Oral Dissolution Technique.
• Patients suffering from gallbladder pain who are obese and who have calcified gallstones or stones made up of bile products probably will not get benefit from this approach.
• About 25% of people can undergo “Oral Dissolution Technique.” This treatment takes up to a couple of years and is cost prohibitive.

• Doctor often diagnose acute cholecystitis on physical assessment depending on symptoms like constant and acute pain in upper right part of abdomen.
• Ultrasound of the abdomen or other imaging techniques is used to detect gallstones which could be causing gallbladder pain.
• Endoscopic Ultrasound (EUS) is an ultrasound variation, which is also helpful in detecting gallstones.
• Cholescintigraphy or HIDA scan is an imaging technique which has greater sensitivity than ultrasounds in the diagnosis of acute cholecystitis causing gallbladder pain. It is non-invasive and takes about a couple of hours.
• ERCP is usually a standard procedure for detecting CBD stones; however, this is an invasive technique and hence there is a risk for complications like pancreatitis.
• CT scan is a valuable technique if patient has some complications like perforation, CBD stones, and other issues like pancreatic cancer or gallbladder cancer.
• Helical CT scan is more advanced and is very fast and gives out clear images.
• MRCI or MRCP are other techniques beneficial for detecting CBD stones and some other abnormality in biliary tract.
• Virtual endoscopy is under research. It uses data available from CT and MRI to give a 3D view of various structures of body. This is non-invasive and has the capacity to find out small stones in CBD than MRI.
• Standard x-rays of the abdomen may detect calcified gallstones and gas. Variations of this include oral cholecystography or cholangiography
• Blood tests: Bilirubin and alkaline phosphatase is found to be more in acute cholecystitis, specially in CBD stones. Elevated bilirubin levels cause jaundice and the skin tends to have yellowish tinge.

Liver enzymes, AST and ALT, is elevated with CBD stones. Elevated WBC count is present in quite a few individuals with cholecystitis.

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