- What Is Cholecystitis?
- Common Symptoms of Cholecystitis
- Acute vs. Chronic Cholecystitis
- Common Causes of Cholecystitis
- Diagnosing Cholecystitis
- Gallstones and Complications: Detection and Treatment
- Acute cholecystitis
- When to seek medical advice
- What causes acute cholecystitis?
- Who is affected
- Diagnosing cholecystitis
- Treating acute cholecystitis
- Possible complications
- Preventing acute cholecystitis
- gallbladder attack, pain, how long can it last for ?
- Symptoms and Signs: Gallbladder Attack
- Symptoms of Gallstones
- Gallstone Q&A
What Is Cholecystitis?
Cholecystitis is often diagnosed using ultrasound imaging tests. James Cavallini/Alamy
The gallbladder is a small organ that holds bile from the liver and releases it into the small intestine to help with digestion. (1)
When a gallstone forms, it can wedge itself in the ducts that release bile — causing bile buildup and a painful condition called cholecystitis. (2)
Cholecystitis, or gallbladder inflammation, occurs when bile can’t circulate out of the gallbladder as it normally does.
When bile builds up, it causes the gallbladder to thicken, harden, swell, and become irritated.
The abdomen becomes painful, and infection can occur if bile can’t flow properly. (3)
Common Symptoms of Cholecystitis
The most common symptoms of cholecystitis are:
- Severe and sudden pain in the upper right part of the abdomen
- Pain that spreads to your right shoulder or back
- Pain after eating a meal
- An abdomen that’s tender to the touch
- Bloated belly (2,3)
Symptoms of cholecystitis often occur after a large or fatty meal.
Although it’s easy to mistake the symptoms of cholecystitis for some other simple problem, it’s important to get a proper medical diagnosis.
Untreated cholecystitis can lead to complications, so don’t brush off these symptoms as just a little indigestion or a stomach bug. (3)
Acute vs. Chronic Cholecystitis
Cholecystitis can be chronic — persistent and long-lasting swelling and damage to the gallbladder — or acute, a sudden “attack” that causes swelling and irritation of the gallbladder.
Acute cholecystitis involves pain that begins suddenly and usually lasts for more than six hours. It’s caused by gallstones in 95 percent of cases, according to the Merck Manual.
An acute attack usually goes away within two to three days, and is completely resolved within a week. If it doesn’t resolve within a few days, you may have a more severe complication.
Acute cholecystitis can develop into chronic cholecystitis.
Chronic cholecystitis is defined by repeated attacks of pain caused by blockages in the biliary ducts, almost always due to gallstones.
Pain in chronic cholecystitis tends to be less severe than in acute cholecystitis and doesn’t tend to last as long. Fever is also rare in chronic cholecystitis.
If you have chronic cholecystitis, your gallbladder may become scarred and small, with a thick outer wall. It may also contain sludge (a thick substance that pollutes the gallbladder and can’t be absorbed) or calcium deposits, which can harden and further damage the organ. (4)
Common Causes of Cholecystitis
Some of the most common causes of cholecystitis include:
- Gallstones becoming lodged in the ducts of the gallbladder, preventing bile from emptying
- Scarring in the bile ducts leading to blockage, which can rarely happen without gallstones
- A tumor in the liver or pancreas
- Reduced blood flow to the gallbladder, sometimes due to damaged blood vessels from a severe illness
- A bacterial or viral infection that strikes the bile duct system, which empties bile from the gallbladder (this may be a complication of AIDS) (3)
A rare form of acute cholecystitis that isn’t due to gallstones — called acalculous cholecystitis — tends to occur after the following events and conditions:
- Major surgery
- Serious illness, infection, or injury
- Long-term intravenous (IV) feeding
- Extended fasting
- Immune system deficiency (4)
Cholecystitis can be easily diagnosed through a physical exam, medical history, and an ultrasound or other imaging test.
In most cases, an ultrasound can detect gallstones, in addition to fluid around the gallbladder and thickening of its walls. The procedure can also reveal tenderness in the area.
A computed tomography (CT) scan may be used if an ultrasound doesn’t produce adequate images.
If acute cholecystitis isn’t seen on other imaging tests, another procedure called a hepatobiliary iminodiacetic acid (HIDA) scan may be used.
This imaging test involves injecting a small amount of a harmless radioactive substance into your arm. A device called a gamma camera is then used to create images as this substance travels from your bloodstream to your liver, gallbladder, bile ducts, and small intestine. (3)
Gallstones and Complications: Detection and Treatment
Drs. Simpson, Yen and Ahmed are from the Department of Medicine, Division of Gastroenterology, Stanford University School of Medicine, Stanford, California and *Division of General Internal Medicine and Geriatrics Veteran’s Administration Medical Center, San Diego, California University of California, San Diego School of Medicine, San Diego, California.
We all have a gallbladder but most of us do not spend much time thinking about it. Those that do are probably among the 25 million or so Americans who suffer from gallstones.
The pear-shaped gallbladder sits below the liver in the upper right-hand corner of the abdomen. It is connected to the liver and to the small intestine by several tubes called bile ducts. Its purpose is to store bile, a liquid which is produced by the liver that helps us digest fat. After a meal, the gallbladder contracts and sends bile into the intestine. Once a meal has been digested, the gallbladder stops sending bile and returns to its old job of storing up bile for our next steak dinner.
What is a Gallstone? Bile is a brown liquid made up of bile salts, cholesterol, bilirubin and lecithin. Bile salts and lecithin help break up fat so that it can be digested more easily. Bilirubin, which gives both bile and stool their characteristic color, is a waste product.
Problems begin when some of the components of bile form hard crystals (or stones). Most gallstones are made up of either cholesterol or bilirubin but not both. Because they range in size from as small as a grain of sand to as large as a golf ball, a gallbladder may contain anywhere from one stone to hundreds. These gallstones may cause problems in the gallbladder or in the bile duct, or they may cause no problems at all.
We are not sure why gallstones happen but we do know that people with high levels of cholesterol in their bile are more likely to develop cholesterol stones and those with high levels of bilirubin are more likely to develop bilirubin stones. Problems with the gallbladder muscle, causing incomplete emptying of the gallbladder, also seem to play a part in gallstone development. Exactly how diet affects gallstone formation is not well understood but it is suspected that a diet high in cholesterol and fat can increase a person’s risk of developing gallstones
Really Bad Pain The most typical first sign of gallstones is pain — sometimes excruciating pain — in the upper abdomen or right side. This is sometimes accompanied by fever, vomiting or sweating. The most common treatment is surgical removal of the gallbladder, although there are other treatments, depending on the type of gallstone, the severity of a person’s attacks and the presence of complications such as infection.
Most treatments are much more successful if they are given early on. Anyone who thinks they might have gallstones should see a doctor as soon as possible.
- steady pain in the upper abdomen that worsens rapidly and lasts as long as several hours
- pain in the back between the shoulder blades
- pain under the right shoulder
- nausea or vomiting
- abdominal bloating
- recurring intolerance of fatty foods
- low-grade fever
- yellowish color of the skin or whites of the eyes
- clay-colored stools
Table 1. Risk Factors for Cholesterol Gallstone Formation.
- Increasing age, female sex
- Ethnicity: Pima Indians, Scandinavians
- Family history of gallstones on the mother’s side
- Obesity, rapid weight loss, fasting, tube feeding or total parenteral nutrition (TPN)
- Drugs: fibric acid derivatives, cholesterol-reducing drugs, contraceptive steroids (birth control pills) and postmenopausal estrogen, progesterone, octreotide, ceftriaxone (hormone replacement therapy)
- Crohn’s disease, certain types of surgery involving the digestive system, hyperlipidemia (excess fat in the bloodstream) and diabetes.
A Gallstone Attack As many as one-third of patients with gallstones have symptoms; the remaining two thirds either never know that they have the disease or find out accidentally, for instance by having an X-ray or CT scan for another purpose. The most common symptom is called biliary colic; this occurs in 70% to 80% of gallstone sufferers. The main feature of biliary colic is severe pain above the stomach area or less frequently in the upper right-hand section of the abdomen. The term biliary colic is a little misleading because the pain is steady, not colicky. A large meal may bring on an attack of biliary colic. More often than not, however, there is no warning or apparent cause.
Biliary colic occurs more commonly at night, often with a sudden onset and increasing intensity over a 15-20 minute period, ending in a steady plateau which can last for several hours. The pain may spread to the area around the right shoulder. Nausea, vomiting and sweating often follow. The pain may gradually go away or decrease, becoming a less severe but persistent abdominal pain. The time period between biliary colic attacks is extremely variable; it may be weeks, months or even years.
When the pain of an attack lasts longer than several hours, it may mean that the gallbladder has become inflamed. This condition, called cholecystitis, can lead to an infection of the gallbladder. Patients with cholecystitis are normally hospitalized for observation, treatment with antibiotics and pain medications, sometimes followed by surgery. Elderly people suffering from acute cholecystitis sometimes do not have any pain or fever, and soreness or tenderness in the abdomen may be their only symptom. Jaundice develops in 15% of those with acute cholecystitis.
In some rare cases, acute cholecystitis is caused not by gallstones but by infections such as salmonella food poisoning. Cytomegalovirus and cryptosporidia infections have also been found to cause cholecystitis in severely immunocompromised patients, such as those with AIDS or those who have recently undergone bone marrow transplantation.
How Doctors Diagnose Gallstones Two tests help doctors find gallstones within the gallbladder. The first, ultrasound, uses sound waves to detect hard objects. In the second, oral cholecystogram (or OCG), an X-ray is taken of the gallbladder after the patient swallows pills containing dye. These tests are extremely accurate. Ultrasound is more common because it is non-invasive and does not involve exposure to X-rays.
It is more difficult to detect gallstones that have entered the bile duct because ultrasound is much less sensitive in the bile duct and OCG cannot be used at all. The best tests involve putting X-ray dye directly into the bile ducts. A flexible swallowed tube can be used (endoscopic retrograde cholangiopancreatography or ERCP), or a needle can be passed through the liver and into the bile ducts (percutaneous transhepatic cholangiography or PTC). These tests both carry a small amount of risk, require the use of an X-ray and may be uncomfortable or require patients to be sedated. But thanks to recent technological advances, there is now a non-invasive alternative — CAT scan and MRI data can be processed into a three dimensional image that offers diagnostic accuracy comparable to ERCP.
Gallstone-induced Complications Gallbladder disease often leads to complications that can become a greater health problem than the gallstones themselves:
Cancer According to the studies, 60% to 80% of all gallstones are asymptomatic; that is, they cause no pain or other symptoms. In most cases, this means that little or no treatment is needed. One exception, however, is when asymptomatic gallstones occur in people who are at high risk for developing cancer of the gallbladder. This includes those with a generally calcified (“porcelain”) gallbladder, those with gallstones greater than 2.5 cm in size, those with gallbladder polyps greater than 10 mm in diameter and Pima Indians. People in these categories may want to consider seeking treatment even if they have no pain or other symptoms.
Biliary Colic Studies of gallstone sufferers have revealed that 38% to 50% of those with biliary colic will have another attack within a year. We also know that as much as 90% of gallstone complications, including acute cholecystitis, are preceded by attacks of biliary colic. There is a 1 to 2% per year risk of developing biliary complications after an initial attack of biliary colic. On the other hand, a third of those who suffer an attack of biliary colic will never have a recurrence.
Acute Cholecystitis In most cases, acute cholecystitis is treated with emergency surgery to remove the entire gallbladder (cholecystectomy). The sooner this is done, the better — usually within 24 to 48 hours after diagnosis. Laparoscopic cholecystectomy, also called “belly-button surgery,” is a new technique that is taking the place of traditional open surgery. In the open technique, the gallbladder is removed through an incision in the abdomen several inches long. Four or five days of hospitalization, followed by weeks of recuperation at home, are usually needed.
In the laparoscopic method, the surgeon makes several much smaller incisions in the abdomen through which a tiny video camera and surgical instruments are inserted. Using the video picture as a guide, the surgeon is able to remove the gallbladder through the tiny incisions without making big cuts in the abdominal muscles. After surgery, because the abdominal muscles are intact, there is less pain, faster healing and a much smaller scar. Patients usually leave the hospital in a day and return to their normal routine within a few days. Laparoscopic cholecystectomy is now used for most cholecystectomies in the United States.
A test called hepatobiliary scintigraphy helps doctors determine whether someone is suffering from acute cholecystitis. A liquid called an IDA agent is injected into the gallbladder and computer imaging then tracks the agent as it is passes through the bile duct. If an obstruction is not seen, then the patient’s abdominal pain or other symptoms must be caused by something else.
Choledocholithiasis This is the medical term for the presence of gallstones in the bile duct. In general, patients with jaundice and inflammation of the bile duct should be promptly scheduled for a ERCP examination, and, if necessary, a laparoscopic cholecystectomy within 1 or 2 days.
Alternatives to Surgery There are alternatives to surgery for both stones in the gallbladder and stones in the bile duct. ERCP can be used not only to find stones in the bile duct but also to remove them. For elderly patients or those too frail for surgery, removal of bile duct stones can relieve symptoms. Stones can also be dissolved by certain chemicals taken in pill form. Unfortunately, this works only on small cholesterol stones.
A big drawback of all non-surgical approaches is that gallstones eventually recur in about half of all patients treated.
Life without the Gallbladder We do not know a lot about what causes gallbladder disease or why some people have associated pain and other symptoms while others do not. Fortunately, the gallbladder is one of those rare organs that are fairly easy to live without. Once the gallbladder is removed, bile travels from the liver directly into the small intestine instead of being stored in the gallbladder. Sometimes, as a consequence, people without a gallbladder experience diarrhea but this occurs in no more than about 1 percent of those who undergo the surgery.
Acute cholecystitis is swelling (inflammation) of the gallbladder. It is a potentially serious condition that usually needs to be treated in hospital.
The main symptom of acute cholecystitis is a sudden sharp pain in the upper right side of your tummy (abdomen) that spreads towards your right shoulder.
The affected part of the abdomen is usually extremely tender, and breathing deeply can make the pain worse.
Unlike some others types of abdominal pain, the pain associated with acute cholecystitis is usually persistent, and doesn’t go away within a few hours.
Some people may additional symptoms, such as:
- a high temperature (fever)
- nausea and vomiting
- loss of appetite
- yellowing of the skin and the whites of the eyes (jaundice)
- a bulge in the abdomen
When to seek medical advice
You should see your GP as soon as possible if you develop sudden and severe abdominal pain, particularly if the pain lasts longer than a few hours or is accompanied by other symptoms, such as jaundice and a fever.
If it’s not possible to contact your GP immediately, phone your local out-of-hours service or call the NHS 24 111 service for advice.
It’s important for acute cholecystitis to be diagnosed as soon as possible, because there is a risk that serious complications could develop if the condition is not treated promptly (see below).
What causes acute cholecystitis?
The causes of acute cholecystitis can be grouped into 2 main categories: calculous cholecystitis and acalculous cholecystitis.
Calculous cholecystitis is the most common, and usually less serious, type of acute cholecystitis. It accounts for around 95% of all cases.
Calculous cholecystitis develops when the main opening to the gallbladder, called the cystic duct, gets blocked by a gallstone or by a substance known as biliary sludge.
Biliary sludge is a mixture of bile (a liquid produced by the liver that helps digest fats) and small crystals of cholesterol and salt.
The blockage in the cystic duct results in a build-up of bile in the gallbladder, increasing the pressure inside it and causing it to become inflamed. In around 1 in every 5 cases, the inflamed gallbladder also becomes infected by bacteria.
Acalculous cholecystitis is a less common, but usually more serious, type of acute cholecystitis. It usually develops as a complication of a serious illness, infection or injury that damages the gallbladder.
Acalculous cholecystitis is often associated with problems such as accidental damage to the gallbladder during major surgery, serious injuries or burns, blood poisoning (sepsis), severe malnutrition or AIDS.
Who is affected
Acute cholecystitis is a relatively common complication of gallstones.
It is estimated that around 10-15% of adults in the UK have gallstones. These don’t usually cause any symptoms, but in a small proportion of people they can cause infrequent episodes of pain (known as biliary colic) or acute cholecystitis.
To diagnose acute cholecystitis, your GP will examine your abdomen.
They will probably carry out a simple test called Murphy’s sign. You will be asked to breathe in deeply with your GP’s hand pressed on your tummy, just below your rib cage.
Your gallbladder will move downwards as your breathe in and, if you have cholecystitis, you will experience sudden pain as your gallbladder reaches your doctor’s hand.
If your symptoms suggest you have acute cholecystitis, your GP will refer you to hospital immediately for further tests and treatment.
Tests you may have in hospital include:
- blood tests to check for signs of inflammation in your body
- an ultrasound scan of your abdomen to check for gallstones or other signs of a problem with your gallbladder
Other scans – such as an X-ray, a computerised tomography (CT) scan or a magnetic resonance imaging (MRI) scan – may also be carried out to examine your gallbladder in more detail if there is any uncertainty about your diagnosis.
Treating acute cholecystitis
If you are diagnosed with acute cholecystitis, you will probably need to be admitted to hospital for treatment.
Initial treatment will usually involve:
- fasting (not eating or drinking) to take the strain off your gallbladder
- receiving fluids through a drip directly into a vein (intravenously) to prevent dehydration
- taking medication to relieve your pain
If you have a suspected infection, you will also be given antibiotics. These often need to be continued for up to a week, during which time you may need to stay in hospital or you may be able to go home.
With this initial treatment, any gallstones that may have caused the condition usually fall back into the gallbladder and the inflammation often settles down.
In order to prevent acute cholecystitis recurring, and reduce your risk of developing potentially serious complications, the removal of your gallbladder will often be recommended at some point after the initial treatment. This type of surgery is known as a cholecystectomy.
Although uncommon, an alternative procedure called a percutaneous cholecystostomy may be carried out if you are too unwell to have surgery. This is where a needle is inserted through your abdomen to drain away the fluid that has built up in the gallbladder.
If you are fit enough to have surgery, your doctors will need to decide when the best time to remove your gallbladder may be. In some cases, you may need to have surgery immediately or in the next day or 2, while in other cases you may be advised to wait for the inflammation to fully resolve over the next few weeks.
Surgery can be carried out in two main ways:
- laparoscopic cholecystectomy – a type of keyhole surgery where the gallbladder is removed using special surgical instruments inserted through a number of small cuts (incisions) in your abdomen
- open cholecystectomy – where the gallbladder is removed through a single, larger incision in your abdomen
Although some people who have had their gallbladder removed have reported symptoms of bloating and diarrhoea after eating certain foods, you can lead a perfectly normal life without a gallbladder.
The organ can be useful but it’s not essential, as your liver will still produce bile to digest food.
Without appropriate treatment, acute cholecystitis can sometimes lead to potentially life-threatening complications.
The main complications of acute cholecystitis are:
- the death of the tissue of the gallbladder, called gangrenous cholecystitis, which can cause a serious infection that could spread throughout the body
- the gallbladder splitting open, known as a perforated gallbladder, which can spread the infection within your abdomen (peritonitis) or lead to a build-up of pus (abscess)
In about 1 in every 5 cases of acute cholecystitis, emergency surgery to remove the gallbladder is needed to treat these complications.
Preventing acute cholecystitis
It’s not always possible to prevent acute cholecystitis, but you can reduce your risk of developing the condition by cutting your risk of gallstones.
One of the main steps you can take to help lower your chances of developing gallstones is adopting a healthy, balanced diet and reducing the number of high-cholesterol foods you eat, as cholesterol is thought to contribute to the formation of gallstones.
Being overweight, particularly being obese, also increases your risk of developing gallstones. You should therefore control your weight by eating a healthy diet and exercising regularly.
However, low-calorie, rapid weight loss diets should be avoided, because there is evidence they can disrupt your bile chemistry and actually increase your risk of developing gallstones. A more gradual weight loss plan is best.
Read more about preventing gallstones.
gallbladder attack, pain, how long can it last for ?
thank you all for your kind words, help
my pains generally are gnawing type, with occasional shooting pain. The GERD is not helping. I had a nasty large polyp taken out of colon last December, then I had bad bout of GERD at this time. Once I got back on feet in February this year, I thought that was that
I have elevated liver enzymes too, but this has been know for few years. I am bit concerned about rapid weight lose. Although I guess because I have limited choices with food, this is forcing the weight loss.
Is weird I am getting middle left back shooting pains at times, I guess this could be referred pain, or the kidneys,
when all this happened 4 weeks ago, I nearly passed out at work, paramedics were called, then I was taken to A&E. Blood tests 4 weeks ago obviously showed no concern for kidneys. Although blood test did show I was fighting some kind of infection. ECG test was fine
I have read in other posts that the vagus nerve can play havoc, strange pains, symptoms, with you when GERD is present. Plus I did have an upper gastrointestinal endoscopy when I was poorly in December, this showed smallish hiatus hernia too
the problem I have with current doctors is that my consultant is pushing for heart MRI because of the recent chest pains I was having (these have now calmed down because I am managing my GERD better, dairy seems now to be massive trigger), and I have pre-hypertensive blood pressure too. He seems to want to ignore my local doctors positive Murphy’s sign test that was conducted last week. The consultant and I quote says “the majority of his abdominal/flank symptoms are likely to be musculoskeletal”
I just cannot believe he is saying this. I had serious motorcycle accident when I was 18, I know what musculoskeletal pain is like. The right flank pain (which I have had ever since I got taken ill last November) has always been there, I have constantly told these consultants that this pain is real. Now the pain is very real and with me every day (previously the right flank pain would come and go for days, weeks)
so I am back to the same doctor tomorow who did the Murphys sign test last week, and ask him where do we go from here.
for me I think another ultrasound scan is required (I had one 10 months ago), something has changed since that last scan. Maybe I just have some gallbladder malfunction, inflammation going on without stones
I have read that non-calcified stones can be missed by scans (when I was taken to A&E last November when my health turned poorly first time round, I remember the two mains doctors talking about this to me)
I have no signs of jaundice , but when I eat fatty foods, right flank pain shoots right up, with nausea, dizziness (how can this be musculoskeletal related ? )
sorry I did not include all of this in first post, but I did not want to waffle on too much in first post
And even without symptoms, gallstones also increase your risk of gallbladder cancer. It’s a rare form of the disease, with only around 4,000 new diagnoses each year in the United States, but only around one in five of these are found in the early stages when the cancer hasn’t spread to other organs and is easier to treat.
If your gallstones do happen to be symptomatic instead of silent, here are common signs of a gallbladder attack you should be aware of:
- A sudden, intense, “stabbing, gnawing, cramping” pain in the upper right section of your abdomen
- A similar pain in the center of your abdomen, under your chest, that might make you wonder if you’re having a heart attack
- Pain in between your shoulder blades
- Pain that radiates into your right shoulder
If your gallbladder attack continues without treatment, the symptoms can become even more serious and progress to:
- Abdominal pain that lasts longer than five hours and is so severe you can’t sit still
- Jaundice (when your skin and the whites of your eyes take on a yellow tinge)
- Pee that looks tea-like
- Poop that is strangely light
Your gallstones can also affect your pancreas in what’s known as gallstone pancreatitis, which is when your gallstones block the movement of digestive enzymes from your pancreas leading to inflammation, according to the American College of Gastroenterology. The symptoms are similar to regular gallstone symptoms, but with a few extras thrown in:
- Sharp, squeezing pain in your upper left abdomen
- Similar pain in your back
If you’re having any of the above symptoms, seek medical attention immediately.
What are the chances I’ll have a gallbladder attack?
While anyone with a gallbladder can develop gallstones, there are many known risk factors for developing them. Here are some common ones:
- Being a woman: This is because estrogen can boost bile’s cholesterol levels and make your gallbladder contract less, according to the NIDDK.
- Being over 40: Your cholesterol levels rise as you get older.
- Losing weight too quickly: Dropping pounds, especially through fasting or other extreme means, is hazardous because it makes your liver excrete more cholesterol into your bile, raising your risk of gallstones.
- Being obese or having diabetes: On the other hand, being obese can increase the cholesterol in your bile so it’s also a risk factor, as are type 1 and type 2 diabetes.
- Having certain health conditions: Conditions like Crohn’s disease that screw up your body’s absorption of nutrients can also lead to gallstone formation.
- Having a family history of gallstones: If members of your immediate family have had gallstones, you’re at a higher risk of having them too.
- Being of a certain cultural descent: American Indians have the highest rate of gallstones, according to the NIDDK. The reason: Certain genetic factors can increase the cholesterol in this population’s bile. Mexican Americans also have a high risk of developing gallstones, potentially due to this group having higher rates of American Indian ancestry.
How is a gallbladder attack treated?
Treatment depends on whether you’re having a regular gallbladder attack or are experiencing gallstone pancreatitis. To figure out what’s going on doctors will likely do an imaging test like a CT scan or ultrasound; tests to check the state of your bile ducts; blood tests; or use a thin, flexible tool known as an endoscope to evaluate your stones. They also may give you medications for the pain.
Symptoms and Signs: Gallbladder Attack
What Causes Galbladder Attacks?
Gallstones have a tendency to become lodged in the bile ducts leading from the gallbladder or liver into the intestines. When gallstones lodge in the ducts, they give rise to a specific type of pain called biliary colic. The characteristics of biliary colic are very consistent, and it is important to recognize its characteristics because they direct the physician to the most appropriate test to diagnose gallstones, primarily abdominal ultrasonography.
In approximately 5% of cases, ultrasonography will fail to show gallstones. In such situations, if the characteristics of biliary colic are typical, physicians will go on to other more advanced tests for diagnosing gallstones, specifically endoscopic ultrasound. Finally, most gallstones do not cause pain, and are frequently found incidentally during abdominal ultrasonography. If the symptoms for which the ultrasonography is being done are not typical of biliary colic, it is unlikely that the symptoms are caused by gallstones. The gallstones can be truly silent. This is important to recognize because surgery to remove the gallstones is unlikely to relieve the symptoms.
When gallstones lodge suddenly in the duct leading from the gallbladder (cystic duct), the duct leading from the liver to the cystic duct (common hepatic duct), or the duct leading from the cystic duct to the intestine (common bile duct), the normal flow of bile from the liver is interrupted. With obstruction of the common hepatic or common bile duct, the backup of bile causes the ducts (and the gallbladder in the latter case) to distend. This distention (stretching) is the cause of the biliary colic. When obstruction of the cystic duct occurs, fluid is secreted into the gallbladder causing it to distend. Again, the distention causes biliary colic. Biliary colic stops when the gallstone unlodges from the duct.
The sudden obstruction of the bile ducts causes biliary colic. Other processes that suddenly obstruct the ducts also can cause biliary colic, for example, bleeding into the ducts or the entry of parasites into the ducts, but these causes are rare. The occurrence of slowly progressive obstruction does not cause biliary colic unless sudden obstruction is superimposed upon the progressive obstruction. For this reason, it is uncommon for slowly growing cancers of the bile ducts, gallbladder, or pancreas (through which the common bile duct passes) to cause biliary colic.
Diagnosis of gallstones as cause of biliary pain In addition to ultrasonography, it may be useful to obtain blood tests to assess the liver function (aminotransferases) and pancreas (amylase). If the tests are abnormal they support the diagnosis of a process involving the liver, bile ducts and gallbladder, or pancreas. They do not indicate specifically what the problem is, but an early rise and rapid fall in their levels suggests obstruction of the biliary ducts. Endoscopic ultrasonography is the best test for diagnosing gallstones, but it is expensive and carries the risk of complications.
Cholecystitis may occur as a complication of prolonged obstruction of the ducts. It occurs when inflammation develops, usually as a result of bacterial infection. If it results as a complication of sudden obstruction of the ducts, it may begin as biliary colic. Less commonly, it may begin de novo, that is, without the pain that is typical of biliary colic, particularly in situations in which the underlying cause is not gallstones (for example, acalculous cholecystitis, vasculitis, etc.).
The pain of cholecystitis is different from biliary colic. It is located in the same area and is constant, but since the cause of the pain is inflammation and not ductal distention, jarring motion, for example, jumping up and down, makes the pain worse. Individuals tend to lie still rather than move about looking for a position of comfort. Other signs of inflammation are tenderness in the right upper abdomen (although this may occur to a lesser degree with distension of the gallbladder without inflammation) and fever.
Symptoms of Gallstones
Typical symptoms of gallstones are of three types:
- Pain between the breast bone and the belly button (epigastric) pain or discomfort
- Pain beneath the breastbone (substernal), which may seem like a heart attack
- Pain in the right upper quadrant, which may shoot to the right side of the back or up to the right shoulder
These pains, which are referred to as biliary colic, may be mild or severe, sharp or crampy, and may last from minutes to hours. They typically occur a few hours after eating and most commonly at night or early morning. They frequently wake the patient from sleep. The pain may be associated with nausea and vomiting. It is often associated with bloating. In fact, bloating and fullness are common symptoms that may be related to gallstones and unassociated with pain.
However, bloating and fullness may occur for other reasons. If that is the case, treatment of the gallstones will not lead to relief of the symptoms. In fact, the only reliable symptoms of gallbladder disease, which will almost always be eliminated by removing the gallbladder, are the three pain syndromes noted above.
Do the pain and symptoms occur in all patients with gallstones?
No. There are over 20 million Americans with gallstones but only about 750,000 gallbladders removed per year. In addition, about 1 million new cases will be diagnosed each year. Therefore, most patients with gallstones have no symptoms or symptoms so mild they do not affect their lifestyle. It is estimated that only 20% of people with gallstones and no symptoms will develop symptoms during the next twenty years of their life. However, people who do have symptoms are likely to continue to have symptoms. Furthermore, in a large percentage of symptomatic patients, the frequency and severity of the attacks increase over time.
Why do these symptoms occur?
After we eat there are chemical (hormonal) and nerve signals from our intestinal tract (duodenum) which cause the gallbladder to contract. When there are no stones present, the gallbladder empties its bile freely. However, when stones are present, the stones can block the exit of the gallbladder at the cystic duct. This leads to secretion of water into the gallbladder to relieve the obstruction by increasing the force of contraction. However, because the exit is blocked, this leads to distention (swelling) of the gallbladder, which in turn causes the epigastric and or substernal pain.
Continued distention of the gallbladder leads to reduced blood flow to the wall of the gallbladder and to inflammation. This is associated with pain in the right side of the upper abdomen. The nausea, vomiting and bloating are a non-specific intestinal response (visceral response) to these insults.
Usually after a period of time, the stone will fall out, bile will exit, the distention is relieved and the pain goes away. However, if there was a lot of inflammation, some residual discomfort may remain for hours to days. The length of time this residual pain is present is related to the severity of the attack. Occasionally, the stone gets firmly stuck and does not fall back into the gallbladder. This leads to continued inflammation and pain known as acute cholecystitis. This situation is similar to acute appendicitis although the gallbladder is not as likely to rupture as the appendix is. Typically, patients with acute cholecystitis have large gallstones. They are much sicker than patients with biliary colic, frequently have a fever and need emergency or urgent surgery.
What are my chances of more symptoms?
The National Cooperative Gallstone Study was performed in the early 1980’s to evaluate this question as well as other. The results of these studies revealed that 70% of patients with previous symptoms had at least one more episode of pain during a two year period if the gallstones were not treated. Furthermore, approximately 50% had severe attacks and 20% had more than one attack. Therefore, you can expect attacks in the future if you have had them in the past. The question is when they will occur. Unfortunately, they often will occur when you least want them, Murphy’s Law.
No. Patients may have one small stone and have severe and repetitive symptoms while others with multiple large stones may have none. However, it is important to note that the type of symptoms and complications of gallstone disease are related to the size of the stones. For example, patients with gallstones greater than one centimeter in size are more likely to get acute cholecystitis than those with gallstones less than one centimeter in size. Patients with gallstones greater than 3 centimeters in diameter are more likely to get gallbladder cancer than those with stones smaller than 3 centimeters or no stones. (Nonetheless, gallbladder cancer is so rare it is not a problem worth worrying about.) Patients, on the other hand, with small, less than 1/2 centimeter stones are more likely to get passage of the stones through the cystic duct into the common duct. This can lead to two severe and life threatening problems: pancreatitis and obstructive jaundice.
- Pancreatitis is a chemical inflammation of the pancreas, the organ that makes insulin and digestive enzymes that break up food in our intestinal tract. It results from the passage of a stone down the common duct and out the end of the common duct into the intestine. As the stone passes through, it can block the exit of the duct from the pancreas which also empties into the common duct or the intestine near the common duct. Because the pancreatic duct contains digestive enzymes that breakdown food, the blockage can lead to digestion of the pancreas itself. As a result, patients with acute pancreatitis can develop severe complications and death. Acute pancreatitis is usually associated with severe pain in the epigastrium that radiates straight back, is worse lying down and better sitting up. It is associated with vomiting and retching.
- Obstructive jaundice from stones (choledocholithiasis) is the condition whereby stones enter and block the flow of bile in the common duct from the liver to the duodenum. This results in a back up of bile which causes the liver to not work correctly, fats to be malabsorbed, the eyes and skin to turn yellow, the urine to turn tea colored and the stool to turn clay colored. Because the bile becomes stagnant in the common bile duct, the risk of infection is great and can be life threatening. It is usually associated with severe pain in the epigastrium.
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