Fast Five Quiz: Test Your Knowledge of Gallstones

Jamie Shalkow, MD;  Daniel Margain, MD


June 12, 2018

In severe cases of acute cholecystitis, ascending cholangitis, or acute pancreatitis, bowel sounds are often absent or hypoactive. In acute cholecystitis, inflammation of the gallbladder with resultant peritoneal irritation leads to a well-localized pain in the right upper quadrant, usually with rebound and guarding. Although nonspecific, a positive Murphy sign (inspiratory arrest on deep palpation of the right upper quadrant during deep inspiration) is highly suggestive of cholecystitis. Fever is often present, but it may lag behind other signs or symptoms. Although voluntary guarding may be present, no peritoneal signs are found. Tachycardia and diaphoresis may be present as a consequence of pain. These should resolve with appropriate pain management. Pain in acute cholecystitis is best managed with antispasmodics and nonsteroidal anti-inflammatory drugs; opioids are not recommended because they increase the pressure in Oddi sphincter and gallbladder contractility, worsening the symptoms. No oral consumption also helps with pain management, whereas gastric drainage has not demonstrated symptom improvement.

Because they are common, gallstones often coexist with other gastrointestinal conditions. Little evidence supports any causal association between gallstones and chronic abdominal pain, heartburn, postprandial distress, bloating, flatulence, constipation, or diarrhea.

Pain termed biliary colic occurs when gallstones or sludge fortuitously impact in the cystic duct during a gallbladder contraction, increasing gallbladder wall tension. In most cases, the pain resolves over 30-90 minutes as the gallbladder relaxes and the obstruction is relieved. Episodes of biliary colic are sporadic and unpredictable. The patient localizes the pain to the epigastrium or right upper quadrant and may describe radiation to the right scapular tip (Collins sign). The pain begins postprandially (usually within an hour after a fatty meal), is often described as intense and dull, and may last from 1 to 6 hours. From onset, the pain increases steadily over about 10-20 minutes and then gradually wanes when the gallbladder stops contracting and the stone falls back into the gallbladder. The pain is constant in nature and is not relieved by emesis, antacids, defecation, flatus, or positional changes. It may be accompanied by diaphoresis, nausea, and vomiting.

For more on the presentation of cholelithiasis, read here.


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