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Biliary Pain Without Gallstones

By Ali A. Siddiqui, MD, Professor of Medicine, Division of Gastroenterology, Thomas Jefferson University

Pain similar to that caused by gallstones sometimes occurs in people who have no gallstones or who have gallstones too small to be detected by ultrasonography. It is called acalculous biliary pain.

Acalculous biliary pain is most common among young women.

This disorder may develop when bile (produced by the gallbladder) does not pass through the ducts into the small intestine as it usually does. Passage of bile may be slowed or blocked because

  • Gallstones, which may be too small to be detected by ultrasonography, are present.

  • For unknown reasons, the gallbladder does not empty normally.

  • The biliary tract or small intestine is overly sensitive.

  • The ring-shaped muscle between the common bile and pancreatic ducts and small intestine (sphincter of Oddi) malfunctions.

  • Gallstones may have blocked the ducts, then passed through before they were detected.

Some people with acalculous biliary pain eventually develop other unexplained (functional) disorders of the digestive tract.

Doctors suspect this disorder if people have biliary pain but ultrasonography shows no stones.

The best way to confirm the diagnosis is unclear. Usually, cholescintigraphy, a type of radionuclide imaging, is done after people are given a drug that causes the gallbladder to contract. If the gallbladder does not fully contract, removing the gallbladder may cause symptoms to resolve.

Surgical removal of the gallbladder (cholecystectomy) is usually done using a flexible viewing tube called a laparoscope. After small incisions are made in the abdomen, the laparoscope and surgical instruments are inserted through the incisions. Doctors then use instruments to remove the gallbladder.

Cholecystectomy may also cause symptoms to resolve if they were caused by gallstones that are too small to be detected by ultrasonography.