Clinical evaluation for gallstone disease: usefulness of symptoms and signs in diagnosis

Patients with gallstones who have recently experienced biliary tract pain are likely to develop recurrent symptoms in the near future. As a consequence, most symptomatic patients are offered specific treatment. However, disagreement persists regarding which symptoms and signs truly represent symptomatic cholelithiasis. We re-examined the relation of gastrointestinal complaints and physical findings to the presence of gallstones in a clinical population.

Over a 2-year period, we identified outpatients of a public teaching hospital for whom diagnostic studies of the gallbladder had been ordered. Patients were interviewed and examined by research personnel prior to completion of the studies. Gastrointestinal symptoms and physical examination findings in 122 patients found to have gallstones were contrasted with those of 178 gallstone-free patients.

In comparison to control subjects, patients with gallstones more often reported epigastric pain lasting at least 30 minutes (64.2% versus 45.1%, p less than 0.004). The latter patients infrequently complained of lower abdominal pain (12.3% versus 29.9%, p less than 0.002), but more often described pain radiating to the upper back. Gallstone-associated pain usually occurred more than 1 hour after meals, persisted from 1 to 24 hours, and was steady in quality. Although these differences were statistically significant, likelihood ratio analysis indicated that clinical symptoms and signs were relatively weak discriminators of gallbladder disease.

Upper abdominal pain is the symptom most closely associated with gallstone disease. Radiation to the upper back, a steady quality, duration between 1 and 24 hours, and onset more than an hour after meals support the diagnosis. Nevertheless, gallstone-associated symptoms are non-specific, and accurate diagnosis cannot rely on the clinical assessment alone. Careful clinical evaluation can guide patient selection for diagnostic imaging and the appropriate management of those found to harbor stones.