Gallstones' Bark Is Bigger Than Its Bite

Medical Author: Jay W. Marks, MD
Medical Editor: Dennis Lee, MD

A patient came to see me for a second opinion about having his gallbladder removed surgically. Although the patient was anxious for the surgery, the referring physician had some doubts. I took a careful history from the patient, examined him, and reviewed the ultrasound study that had found his gallstones.

There was no doubt that the patient had gallstones; the ultrasound was clear. What was not so clear was whether his gallstones were responsible for his most troublesome symptom. Gallstones usually, though not always, cause a characteristic type of abdominal pain referred to as biliary colic. Although the patient had had several episodes of pain that were fairly typical of gallstones, his most frequent and bothersome discomfort was not typical of biliary colic. It was more dyspeptic than biliary. That is, the discomfort was related to meals. (Although it is generally believed that pain from gallstones occurs mostly after meals, studies have shown that this is not so. The pain occurs most commonly in the evening after falling asleep.)

I discussed my thoughts with the patient and concluded by telling him that although I thought his gallstones were causing pain, his most bothersome symptom was not likely to be caused by his gallstones. I had an uneasy feeling that he did not understand what I was telling him. "Doc, I'm so uncomfortable I've got to have this surgery." I responded that there was no more than a 50/50 chance of surgery relieving him of his most troublesome symptom. I still had doubts about his understanding.

Several months later I happened to be in the patient's referring physician's office to pick up some papers. As I passed through the waiting room I noticed the patient that I had seen for a second opinion, and I said hello to him. When I saw his physician I asked him what the patient was seeing him for. As I had predicted, the patient's most troublesome symptom had not disappeared after the surgery. He was now seeing the physician for further help in diagnosing and treating his continuing problem.

Every now and then you run across patients who believe strongly that surgery will cure their problem, and it is difficult to convince them otherwise. Perhaps the strength of their conviction is due to a feeling that since surgery is such a major event, it must be capable of curing anything, or it may be that they are so uncomfortable that they are desperate and are willing to try anything no matter how irrational. Fortunately, I think that the patient needed the surgery since he probably was having pain from his gallstones at least occasionally. I just felt badly knowing how disappointed he must have been when the symptom he was most troubled by was not relieved by the surgery. It would have been preferable to diagnose and treat the cause of the symptom, see if the symptoms more typical of gallstones continued (since it was still possible that these more typical symptoms were not due to gallstones), and, if they did, to recommend removal of his gallbladder.

The real lesson to be learned from this experience, however, is that if the symptoms don't fit the disease, it's likely that the disease is not causing the symptoms - the more atypical the symptoms, the more unlikely. When it comes to abdominal discomfort, there are many very common causes-irritable bowel syndrome, functional dyspepsia, acid-peptic diseases (ulcers, gastritis, gastroesophageal acid reflux , etc.). It's true that gallstones also are common, but half of all gallstones cause no symptoms. Therefore, when they are found, they may be "innocent bystanders." The symptoms may be confusing. Sometimes it is reasonable to recommend surgery even when there is uncertainty about the gallstones being the cause, but not until all efforts have been made to diagnose other possible causes for the symptoms and other treatments have been tried.

Surgery works, but only if it is done for the right reasons.