Is biliary pain exclusively related to gallbladder stones? A controlled prospective study

BACKGROUND: The uncertainty around true clinical manifestations of gallbladder stone disease is in contrast with the unanimous recommendation that only symptomatic gallstones should be treated. AIM: To evaluate the relationship between biliary pain, other gastrointestinal symptoms and gallstones. DESIGN OF STUDY: A pragmatic, prospective cohort questionnaire study. SETTING: Seventy-five general practices in Rotterdam, The Netherlands. METHOD: All patients suspected by their general practitioner (GP) to have gallstone disease underwent ultrasound examination of the upper abdomen. Using a self-administered questionnaire, the presence of 11 gastrointestinal symptoms was assessed at inclusion and after 1 year. Likelihood ratios (LRs) for the presence of gallstones and symptom relief rates after 1 year were calculated. The mean difference in health status at inclusion and after follow-up was calculated for patients without gallstones, for patients with gallstones who were operated on and for patients with gallstones who were not operated on. RESULTS: In total, 61% of the patients with gallstones diagnosed by ultrasound scan reported biliary pain, as did 45% of the patients without gallstones (LR = 1.34, 95% confidence interval [CI] = 1.05 to 1.71). Patients operated on for gallstone disease did not show significant relief of biliary pain compared to patients not operated on for gallstones or patients without gallstones (87%, 63% and 83%, respectively). Health status improved in all patients. The mean improvement in health status did not differ between the three patient groups. GPs were able to discriminate between patients with high and low probability of gallbladder stones by ultrasound examination (53% versus 23%). This selection, however, did not predict the outcome of cholecystectomy. CONCLUSION: Neither biliary pain nor any other gastrointestinal symptom was consistently related to gallstone disease. Therefore, the indication for elective cholecystectomy cannot be based on the presence of biliary pain alone. Relief of biliary pain in patients operated on for gallstones should not simply be attributed to a successful cholecystectomy.