Where is the gallbladder located?
Diagram 1. Gallbladder is located below the right rib cage.
(free image use)
Medical terms and definitions:
- Biliary system refers to the gallbladder and the ducts that carry the bile from the liver to gallbladder and from the gallbladder to small intestine.
- Biliary colic refers to sudden pain in the gallbladder or common bile duct.
- Cholecystitis is an inflammation of the gallbladder.
- MRI is magnetic resonance imaging.
Where can you feel gallbladder pain?
Gallbladder pain occurs in the upper right abdomen below the lowest ribs, or in the upper central abdomen, below the breastbone.
Diagram 2. Gallbladder pain and referred pain location
(free image use)
What does gallbladder pain feel like?
- Sudden mild pain that within 15-60 minutes develops to moderate to severe dull and constant pain, which can last from several minutes to few days.
- Pain can be worse during deep breathing.
- It can appear within few hours after large meals–not only after fatty meals–or at any time, commonly at night.
- It is not relieved by antacids, vomiting, passing gas, a bowel movement or by changing body position.
- It is recurrent; it occur every few days, months or years.
- References: (1,2,3,4)
Other Symptoms and Signs of a Gallbladder Disease
- Nausea or vomiting that occur only when pain occurs (1)
- Occasional symptoms: fever, jaundice, itchy skin, dark urine and pale stools
- Occasional signs: tenderness to touch or a palpable lump in the right upper abdominal quadrant
Indigestion, dyspepsia after fatty meals, abdominal bloating, excessive belching, constipation or diarrhea are not specific for a gallbladder disease – they can also occur in other abdominal disorders (1,2,4).
Causes of Gallbladder and Bile Duct Pain
Gallstones in the gallbladder
Cholecystitis (inflammation of the gallbladder)
Gallstones in the bile duct
Biliary colic without gallstones
Chronic biliary pain
Biliary colic after gallbladder removal
Complications of a gallbladder disease
Gallstones in the Gallbladder (Cholelithiasis)
Gallstones can develop when the gallbladder empties slowly or when the bile contains too much cholesterol (cholesterol gallstones) or bilirubin (pigment gallstones) (3).
Risk factors for gallstones include female sex, obesity, rapid weight loss (>3 pounds/week), bariatric surgery, prolonged fasting, starvation, pregnancy, oral contraceptives, medications (fibrates, estrogen replacement therapy), diabetes type 2, increased breakdown of red blood cells (hemolysis), old age and family history of gallstones (1,2,3). There is no clear connection between the type of diet and gallstones.
Gallstones can be present in the gallbladder for years without causing pain; the pain occurs when the stones block the duct that goes out from the gallbladder (the cystic duct), which results in gallbladder distension.
- Sudden, constant pain in the upper right abdominal quadrant, which typically lasts 1-6 hours (range: 30 minutes to more than 12 hours) (1,4)
- No or only mild tenderness in the upper right abdominal quadrant (1,4)
- No pain or other symptoms between the attacks (1)
Other symptoms include nausea or vomiting. Gallstones without inflammation usually cause no fever.
Diagnosis is by ultrasonography. Treatment is by painkillers and, in recurrent attacks, by gallbladder removal.
Gallstones During Pregnancy
During pregnancy, gallbladder is more relaxed and empties slower, which increases the risk of developing gallstones and gallbladder inflammation, especially in women who had gallbladder disease before pregnancy. When surgery is required, it should be optimally performed in the second trimester; both open and endoscopic surgery are considered safe (27).
Gallstones in Children
Gallstones in children are rare; risk factors include hemolytic anemia (breakdown of red blood cells), for example in sickle cell disease, obesity, Crohn’s disease, surgical removal of the last part of the intestine (ileum) and prolonged fasting or artificial (intravenous) feeding. Symptoms, diagnosis and treatment are the same as in adults.
Biliary sludge refers to small (1-3 mm) clumps of the concentrated bile that may either dissolve spontaneously or develop into gallstones (2). Biliary sludge can, sometimes, cause pain similar to pain from gallstones, or complications, such as cholecystitis, cholangitis or acute pancreatitis (12).
Diagnosis is by MRI or MRCP. When the gallbladder function–evaluated by HIDA scan–is poor, the recommended treatment is gallbladder removal.
Gallbladder Inflammation (Cholecystitis)
Gallbladder inflammation (cholecystitis) is usually caused by gallstones but can also occur in a gallbladder without gallstones.
- Sudden, constant pain in the right upper abdomen that may last from 6 hours to few days
- Tenderness to touch in the gallbladder area
- Pain during breathing in when a doctor presses upon the gallbladder (Murphy’s sign)
Other symptoms and signs: nausea, vomiting, a palpable lump in the painful area and, sometimes, low-grade fever, excessive sweating or jaundice (2). NOTE: high fever (>101 °F or 38.3 °C) may indicate an infection or other complication which can be a medical emergency.
Recurrent episodes of acute cholecystitis can result in chronic cholecystitis with shrunken gallbladder; it is not clear if chronic cholecystitis causes any symptoms (14).
Diagnosis of cholecystitis is by ultrasound and blood tests. Treatment is by painkillers, antibiotics and surgical gallbladder removal within 78 hours of the attack onset (2).
Gallstones in the Biliary Duct (Choledocholithiasis)
When gallstones move from the cystic duct to the common bile duct (Picture 1), they block the passage of the bile and can cause:
- Pain similar to gallbladder pain lasting from several hours to days
- Dark urine and pale stools
- In case of infection (acute cholangitis): fever and chills
- Reference: (1,4,15,16,18)
Diagnosis and treatment is by ERCP.
Biliary Pain Without Gallstones
Acute Acalculous Cholecystitis
Acute acalculous cholecystitis refers to an acute gallbladder inflammation without gallstones or gallstones that are too small to be detected by ultrasound (biliary sludge).
Risk factors include prolonged fasting, diabetes and infections (hepatitis, infectious mononucleosis, Dengue fever, HIV/AIDS) (2,10).
Gallbladder dyskinesia refers to a motility disorder of the gallbladder that is not related to bile stones or other organic abnormalities.
A spasm in the sphincter of Oddi at the end of the common bile duct can block the normal bile flow and cause dull pain after eating, nausea or vomiting (24). The condition is more common in women who have had their gallbladders removed (22).
Gallbladder polyps are abnormal growths in the gallbladder wall, which, rarely, cause right upper abdominal pain, nausea or vomiting (8). Large polyps (>1.5 cm) may develop into cancers (8).
Chronic Biliary Pain
Primary Sclerosing Cholangitis
Primary sclerosing cholangitis is a rare chronic autoimmune disease of the bile ducts, usually in young adults but also in children. It is strongly associated with inflammatory bowel disease (ulcerative colitis or Crohn’s disease) (19).
Symptoms include chronic pain and a lump (enlarged liver) in right upper abdomen, fatigue, loose, pale and greasy stools, jaundice, itchy skin and weight loss. The disease can lead to cirrhosis, liver failure or cancer of the bile duct (cholangiocarcinoma) (19). The only effective treatment is liver transplantation (19).
Cancer in the Gallbladder or Bile Duct
Gallbladder cancer and cancer of the bile duct (cholangiocarcinoma) are rare. Gallbladder cancer usually develops as a complication of a chronic gallbladder inflammation (cholecystitis) in older people (5). Symptoms include chronic pain in the upper abdominal quadrant, a palpable lump below the right rib cage, lumps (enlarged lymph nodes) around the belly button and above the left clavicle, nausea, vomiting and fever, anorexia and weight loss and, especially in bile duct cancer, jaundice, dark urine and pale (grey, white or yellow) stools (5,6,7).
Diagnosis of gallbladder cancer is by ultrasound, CT or MRI and of bile duct cancer by MRCP or ERCP. Treatment may involve surgical removal of the gallbladder or bile, chemotherapy or radiation therapy (25,37). Except in early stages, prognosis is poor (5).
Pain After Gallbladder Removal (Post-cholecystectomy Syndrome)
Abdominal pain persisting after gallbladder removal is often wrongly called phantom pain, that is imaginary pain, from an organ that does not exist in the body any more. The pain is similar to gallbladder pain and can be initially due to the irritation of the diaphragm by gas instilled during the surgery, but pain that can persist for months or years after surgery can be due to (29):
- Gallstones remained in the common bile duct
- Bile leakage into the abdominal cavity
- Sphincter of Oddi dysfunction
- Biliary reflux–backward flow of the bile into the stomach or esophagus–can cause indigestion, heartburn and burning upper central abdominal pain. Antacids, proton pump inhibitors, such as omeprazole, and prokinetics can help relieve the pain (30).
- Gastroparesis (reduced stomach motility) with nausea, early satiety and upper abdominal bloating.
- Adhesions (scar tissue) pulling on the common bile duct
Diarrhea and excessive gas can occur in some people due to constant bile leakage that irritates the bowel.
Diet After Gallbladder Removal
Some doctors recommend avoiding large meals, high-fat and high-fiber meals for some time after surgery to prevent diarrhea and bloating (31).
Complications of a Gallbladder and Bile Duct Disease
Pancreatitis is inflammation of the pancreas. Causes include obstruction of the lower part of the common bile duct by stones, inflammation or cancer resulting in the obstruction of the pancreatic duct.
Symptoms include sudden, severe, dull, constant pain in the upper (right, central or left) abdomen that may wrap around the side of your body and involve the back; the pain is worse during lying and can last for few days; it be relieved by leaning forward; other symptoms: nausea, vomiting (38).
Life Threatening Complications
High fever (>101 °F or 38 °C), abdominal distension, dizziness or impaired consciousness can speak for one of the medical emergencies:
- Gallbladder rupture
- Peritonitis–inflammation of the peritoneal membrane that covers abdominal organs (39,41)
- A collection of pus in the liver (liver abscess) or in the gallbladder (empyema) (1)
- Sepsis or septic shock–infection with invasion of bacteria into the blood (42)
Abdominal ultrasound can detect:
- Gallbladder stones as small as 2 mm in 95% cases and, sometimes, stones in the common bile duct
- Acute or chronic cholecystitis, gallbladder polyps and cancer (2)
Endoscopic ultrasound–via the tube inserted through mouth into the duodenum–can reveal stones in the common bile duct and biliary sludge (44).
Magnetic resonance imaging (MRI) can show biliary sludge, gallbladder polyps and cancers.
Magnetic resonance cholangiopancreatography (MRCP) provides a detailed image of the gallbladder and bile ducts. A doctor injects a contrast substance into a vein and after some time, when the contrast collects in the gallbladder and bile ducts, a MRI scan is done. MRCP can show stones, tumors and inflammation in the common bile duct (1,2,45).
Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic procedure that involves passing a tube with a camera on its end through the mouth into the duodenum and injecting the contrast substance into the bile duct, followed by an X-ray. ERCP can reveal stones in the common bile duct and enables removal of stones, drainage of the infected duct and cutting the sphincter of Oddi.
X-ray shows gallstones in only up to 20% cases and CT scan in up to 80% cases (43).
Hepatobiliary scintigraphy (HIDA scan) is used to evaluate the gallbladder emptying; poor emptying (ejection fraction <40%) is an indication for the gallbladder removal.
Blood tests can, sometimes, show:
- Increased white blood cells (WBC): in cholecystitis and cholangitis
- Increased liver enzymes or bilirubin: in bile duct obstruction
Pain Relief and Treatment
Analgesics for Severe Pain
- Nonsteroidal anti-inflammatory drugs (NSAIDs): diclofenac injection into the muscle or as a suppository, indomethacin, ketorolac
- Narcotic analgesics: morphine or pethidine injection into the muscle
- Antispasmodics: dicyclomine
- References: (2,11,46)
Analgesics for Mild to Moderate Pain
- Antispasmodics: butylscopolamine (hyoscine butylbromide) tablets
- Opiates: codeine
- NSAIDs: ibuprofen tablets
- Reference: (46)
During pregnancy, NSAIDs (diclofenac, ibuprofen, indomethacin, ketorolac, naproxen) should be avoided in the third trimester because they may cause birth defects, but aspirin, paracetamol and opiates (codeine, fentanyl, morphine, pethidine) appear to be safe (20,23).
Do not eat during a gallbladder attack and drink only plain water to prevent gallbladder contractions (47).
To prevent nausea and vomiting, a doctor can prescribe antiemetics, such as metoclopramide, ondansetron or prochlorperazine (2,46).
In inflammation (cholecystitis, cholangitis), a doctor should give you intravenous antibiotics (not by mouth) (11,17).
Surgical Gallbladder Removal (Endoscopic Cystectomy)
Endoscopic cholecystectomy is a surgical procedure that involves a small incision in the abdominal wall and removing the gallbladder using an endoscope.
Classical open surgery is performed when endoscopic removal is not available or possible.
Other Treatment Options for Gallbladder Gallstones
- Oral gallstone dissolution. When surgery might be risky and when gallstones are small (<5 mm), dissolving stones by ursodeoxycholic acid by mouth for at least 6-12 months can be tried; stone recurrence after this treatment is about 50% (2).
- Extracorporeal shock-wave lithotripsy can be used to break stones smaller than 2 cm; recurrent rate is up to 30% within 5 years (2).
Few things that may help relieve gallbladder pain, according to anecdotal reports:
- Heating pad or castor oil compress
- Hot bath
There is no reliable scientific evidence that gallbladder flush or cleanse using the following herbs or beverages helps to ease gallbladder pain or prevent gallstones (28,35): alfalfa, apple cider vinegar, apple juice, a mixture of beet, carrot and cucumber juice, barberry bark, calendula, catnip, chamomile tea, chicory, dandelion, Epsom salt, fenel seed, garlic, ginger, goldenseal, honey with turmeric, lemonade, milk thistle, nettle, olive oil, peppermint tea, psyllium, quebra pedra, rosemary, salt water, St. John’s Wort, wild yam root, yellow dock and yellow root.
Diet to Prevent Gallstones
The main dietary approach that can help prevent gallstones is avoiding obesity or, if already obese, to lose weight slowly (1-2 lbs/week).
There is insufficient evidence about the preventative effects of the following diet approaches on gallstone formation:
- Low saturated fat, low sugar and high dietary fiber intake
- Vegetarian diet
- Vitamin C supplements
- Caffeine (coffee, green tea)
- Moderate alcohol drinking
- Drinking plenty of water
- References: (32,34,35,36)
Other causes of pain after eating: irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), gastritis or gastric ulcer, food allergy, staph food poisoning
Other causes of sudden right upper abdominal pain: inflammatory bowel disease (IBD), inflammation of the liver (viral hepatitis), small bowel obstruction, aneurysm of the abdominal aorta, eclampsia (increase of blood pressure during pregnancy)
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