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 is gallbladder pain felt?
Gallbladder pain occurs in the upper right abdomen below the lowest ribs, or in the upper central abdomen, below the breastbone.
Gallbladder Referred Pain
Diagram 2. Gallbladder pain and referred pain location
(free image use)
Can gallbladder pain be felt on the left side?
Gallbladder pain can extend from the right over the middle toward the left side of the abdomen, but the pain on the left side alone is not typical for gallbladder problems. In very rare cases, in which the liver and gallbladder are located on the left side, the pain from gallbladder would be on the left side, of course.
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. The pain is steady, not wavy.
- Pain can be worse during deep breathing but is usually not triggered by the body movements.
- It can flare up within few hours after large–not only 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)
How long does gallbladder pain last?
- In gallstones without gallbladder inflammation: several minutes to few hours
- In gallbladder inflammation (cholecystitis): from 6 hours to few days
- In gallbladder or biliary dyskinesia: at least 30 minutes
- In gallbladder cancer: chronic, daily discomfort or dull pain
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, heartburn, constipation or diarrhea are not specific for a gallbladder disease – they can also occur in other abdominal disorders (1,2,4). Gallbladder issues do not seem to be directly connected with headache, but some people believe they can trigger migraine.
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). The pain in SOD can be triggered by stress.
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 that persist despite gallbladder removal can be caused by bile reflux, gallstones trapped in the bile ducts, bile leakage due to accidental bile duct injury, sphincter of Oddi dysfunction or internal scars (adhesions).
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 (1,2,31).
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: (2,11,30)
Analgesics for Mild to Moderate Pain
- Antispasmodics: butylscopolamine (hyoscine butylbromide) tablets
- Opiates: codeine
- NSAIDs: ibuprofen tablets
- Reference: (30)
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 (29).
To prevent nausea and vomiting, a doctor can prescribe antiemetics, such as metoclopramide, ondansetron or prochlorperazine (2,30).
In inflammation (cholecystitis, cholangitis), a doctor should give you intravenous antibiotics (not by mouth) (11,17).
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)
If you already have gallstones, it may help you prevent painful attacks if you avoid big meals and fat-rich meals.
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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