Nature and History of Pain

Taking an accurate history is vital. The nature of the pain can tell us a lot about gall bladder disease, and many of the complications of gall stones can be suggested by the history.

The pain of gall stone disease

In gall stone disease the pain is felt in the right upper quadrant (RUQ) and epigastrium. The increasing severity and addition of associated features reflects passage along the pathophysiological spectrum of disease.

With ascension to consecutive levels of severity of gall stone disease, pain becomes sharper, more severe and well localised. Fever and systemic symptoms develop and get worse, and the patient may ultimately develop symptoms of septic shock.

The pain of biliary colic

The pain of biliary colic tends to be constant, and not colicky, as the name suggests. Biliary colic usually lasts 2-6 hours but can last up to 24 hours. Nausea and vomiting may be associated with the pain, but tend not to predominate.

The pain of chronic cholecystitis

Recurrent biliary colic equals chronic cholecystitis. Chronic cholecystitis is associated with some non-specific symptoms (e.g. fatty food intolerance, early satiety) but these are no more strongly linked to patients with gall stones than those without, and they don’t seem to go away with cholecystectomy.

When the initial pain in acute cholecystitis is dull and poorly localised, the lumen of the gall bladder is distended and the visceral peritoneal nervous fibres are stimulated. As the inflammatory process progresses, leakage of inflammatory fluid stimulates the parietal peritoneum nervous fibres and the pain becomes sharp and well localised.

Learning Bite

Biliary colic tends to refer to the individual episode of pain, while chronic cholecystitis refers to recurrent episodes and associated non-specific symptoms, but there is no precise defining point.