title: Pain attacks in non-complicated and complicated gallstone disease have a characteristic pattern and are accompanied by dyspepsia in most patients: the results of a prospective study.
abstract: OBJECTIVE
  The cardinal indication for surgical treatment of gallstones is pain attacks. However, following cholecystectomy, 20% of patients remain symptomatic. It is unclear to what extent post-cholecystectomy symptoms can be ascribed to persistence of preoperative symptoms or to new pathology. The pain and digestive pattern in gallstone patients has not been defined in a recent setting with ultrasonography as the diagnostic method. The aim of this study was to characterize a pain pattern that is typical for gallstone disease and to describe the extent of associated dyspepsia.
  
  
  METHODS
  A total of 220 patients with symptomatic gallstone disease including complicated disease (acute cholecystitis and common bile duct stones) were interviewed using detailed questionnaires to disclose pain patterns and symptoms of indigestion.
  
  
  RESULTS
  All patients had pain in the right upper quadrant (RUQ) including the upper midline epigastrium. The pain was localized to the right subcostal area in 20% and to the upper epigastrium in 14%, and in the rest (66%) it was more evenly distributed. An area of maximal pain could be defined in 90%. Maximal pain was located under the costal arch in 51% of patients and in the epigastrium in 41%, but in 3% behind the sternum and in 5% in the back. The pain was referred to the back in 63% of the patients. The mean visual analogue scale (VAS) score was very high: 90 mm on a 0-100 scale. A pattern of incipient or low-grade warning pain with a subsequent relatively steady state until subsiding in the same fashion was present in 90% of the patients. An urge to walk around was experienced by 71%. Pain attacks usually occurred in the late evening or at night (77%), with 85% of the attacks lasting for more than one hour and almost never less than half an hour. Sixty-six percent of the patients were intolerant to at least one kind of food, but only 48% to fatty foods. Symptoms of functional indigestion (gastroesophageal reflux, dyspepsia or irritable bowel symptoms) were seen in the vast majority in association with attacks.
  
  
  CONCLUSIONS
  Gallstone-associated pain follows a certain pattern in the majority of patients. The pain is located in a defined area with a point of maximum intensity, is usually referred, and occurs mainly at night with duration of more than one hour. The majority of patients experience functional indigestion, mainly of the reflux type or dyspepsia.
authors.affiliation: Department of Surgery, Rogaland Central Hospital, Stavanger, Norway. tewelde.berhane@broadpark.no
authors.forename: Tewelde
authors.initials: T
authors.lastname: Berhane
authors.forename: Morten
authors.initials: M
authors.lastname: Vetrhus
authors.forename: Trygve
authors.initials: T
authors.lastname: Hausken
authors.forename: Snorri
authors.initials: S
authors.lastname: Olafsson
authors.forename: Karl
authors.initials: K
authors.lastname: Søndenaa
mesh_terms: D000208:Acute Disease; D002764:Cholecystitis / Q000150:complications; D004415:Dyspepsia / Q000150:complications*; D005260:Female; D042882:Gallstones / Q000150:complications* / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000503:physiopathology*; D010147:Pain Measurement; D011446:Prospective Studies; D011795:Surveys and Questionnaires