Gallstone Symptoms: How to Recognise a Gallstone Attack

Gallstone Symptoms and Diagnosis: A Comprehensive Guide

Gallstones affect millions of people in India, yet many patients live with symptoms for months or years before receiving a diagnosis. Understanding the symptoms of gallstone disease and the diagnostic process helps you seek timely medical attention and avoid potentially serious complications.

The Spectrum of Gallstone Disease

Gallstone disease exists on a spectrum from completely asymptomatic to life-threatening complications:

Silent gallstones (60–80% of all gallstones): No symptoms. Discovered incidentally on ultrasound performed for other reasons. Do not require treatment in most cases.

Biliary colic (15–25%): Episodic pain from gallstone obstruction of the cystic duct. The most common symptomatic presentation.

Acute cholecystitis (5–10%): Inflammation of the gallbladder. Requires hospitalisation and surgery.

Choledocholithiasis (10–15%): Gallstones in the common bile duct. Can cause jaundice, cholangitis, and pancreatitis.

Gallstone pancreatitis (3–7%): Gallstone-triggered inflammation of the pancreas. Potentially life-threatening.

Acute cholangitis (1–3%): Bacterial infection of the bile duct. Medical emergency.

Classic Symptoms of Gallstones

Biliary Colic: The Hallmark Symptom

Biliary colic is the classic symptom of symptomatic gallstone disease. Despite the name "colic," the pain is typically constant (not cramping) and severe.

Characteristics:

• Location: Right upper quadrant (under the right rib cage) or epigastrium (upper central abdomen)
• Character: Constant, severe, aching or pressure-like pain
• Onset: Sudden; often begins 30–60 minutes after a fatty meal
• Duration: 1–6 hours; resolves spontaneously (if it persists >6 hours, suspect acute cholecystitis)
• Radiation: Right shoulder tip or between the shoulder blades
• Associated symptoms: Nausea, vomiting, sweating
• Triggers: Fatty meals, large meals, lying on the right side

What causes biliary colic?

When you eat a fatty meal, the hormone cholecystokinin (CCK) is released, causing the gallbladder to contract. If a gallstone is present, the contraction forces the stone against the cystic duct opening, causing obstruction and pain. When the gallbladder relaxes (or the stone falls back), the pain resolves.

Symptoms Between Attacks

Between biliary colic attacks, patients may experience:

• Bloating and flatulence after fatty meals
• Mild indigestion and nausea
• Intolerance to fatty foods
• Mild right upper quadrant discomfort

These symptoms are non-specific and can be caused by many conditions. However, their association with fatty meals and the presence of gallstones on ultrasound suggests gallstone disease.

Symptoms of Complications

Acute Cholecystitis

• Pain: Constant right upper quadrant pain lasting >6 hours (does not resolve like biliary colic)
• Fever: Temperature 38–39°C
• Murphy's sign: Pain on deep inspiration when the right upper quadrant is pressed
• Nausea and vomiting
• Anorexia

Choledocholithiasis (CBD Stones)

• Jaundice: Yellow skin and eyes (develops over 24–72 hours)
• Dark urine: Tea-coloured urine from bilirubin excretion
• Pale stools: From reduced bile in the intestine
• Pruritus: Itching from bile salt deposition in the skin
• Right upper quadrant pain (may be mild or absent)

Acute Cholangitis (Bile Duct Infection)

Charcot's Triad:

1. Right upper quadrant pain

2. Fever with rigors (shaking chills)

3. Jaundice

Reynolds' Pentad (severe cholangitis):

4. Hypotension

5. Confusion

Acute cholangitis is a medical emergency. Go to A&E immediately.

Gallstone Pancreatitis

• Severe epigastric pain radiating to the back
• Nausea and vomiting (severe)
• Fever
• Elevated serum amylase/lipase on blood tests

Conditions That Mimic Gallstone Symptoms

Gallstone symptoms overlap with many other conditions, which is why diagnosis requires investigation:

| Condition | Overlapping Symptoms | Distinguishing Features |

|-----------|---------------------|------------------------|

| Acid reflux (GERD) | Upper abdominal pain, nausea | Burning sensation, worse lying down, responds to antacids |

| Peptic ulcer | Epigastric pain, nausea | Pain relieved by food (duodenal ulcer), worsened by food (gastric ulcer) |

| IBS | Abdominal pain, bloating | Associated with altered bowel habits, no fever |

| Liver disease | Right upper quadrant pain | Abnormal liver function tests |

| Kidney stone | Flank pain | Radiates to groin, haematuria |

| Appendicitis | Abdominal pain | Pain migrates to right lower quadrant, fever |

| Cardiac pain | Upper abdominal pain | Associated with exertion, ECG changes |

Diagnostic Tests for Gallstones

Ultrasound Abdomen (First-Line)

The gold standard for gallstone diagnosis. Sensitivity >95% for gallbladder stones. Safe, inexpensive, and widely available.

What it shows:

• Gallbladder stones (echogenic foci with posterior acoustic shadowing)
• Gallbladder wall thickness (>4 mm suggests cholecystitis)
• CBD diameter (>8 mm suggests obstruction)
• Liver and pancreas (for complications)

Limitation: Only 50–60% sensitive for CBD stones.

Blood Tests

• Liver function tests (LFTs): Elevated bilirubin, ALP, GGT suggest bile duct involvement
• Full blood count: Elevated WBC suggests infection
• Serum amylase/lipase: Elevated in pancreatitis
• CRP: Elevated in inflammation

MRCP

Indicated when CBD stones are suspected (dilated CBD on ultrasound, jaundice, elevated LFTs). Sensitivity >95% for CBD stones. No radiation.

CT Scan

Used for suspected complications (perforation, abscess, pancreatitis).

HIDA Scan

Most sensitive for acute cholecystitis (>95%). Used when ultrasound is inconclusive.

When to See a Doctor

See a doctor within 1–2 days:

• Recurring upper abdominal pain after fatty meals
• Nausea and vomiting with abdominal pain
• Indigestion not responding to antacids

Go to A&E immediately:

• Severe abdominal pain lasting more than 6 hours
• Fever with abdominal pain
• Jaundice (yellow skin or eyes)
• Confusion with fever and abdominal pain

Book a consultation with Dr. Patil: Call +91 80889 54804 or WhatsApp +91 99724 46882.

*Medically reviewed by Dr. Adarsh M Patil, MBBS, MS (General Surgery), Fellowship in Advanced Laparoscopy & Bariatric Surgery (Belgium). Consultant General & Laparoscopic Surgeon, Apollo Clinic Indiranagar, Bangalore.*