12/03/2023
An older man with right-sided back pain
I came across this antique drinks bottle recently. āDoc Chengāsā it says on it, with a very intriguing image of an Asian man, Doc Cheng, presumably? Who was Doc Cheng? What caught my eye was the āCodd neckā of the bottle. The fizzy drink holds a marble up against a rubber seal. To open the bottle, just push the marble down. The bottles were recyclable, but kids wanted the marble in the neck, so loads were broken apparently!
The Codd neck and marble made me think of how gallstone can cause a blockage of the gallbladder, resulting in pain from the gallbladder, often referred into the back or right shoulderblade.
The gallbladder is like a squishy bottle, storing washing up liquid (bile) that the body uses to dissolve the fat in our digestive system.
Bile is produced in the liver and stored in the gallbladder. When we eat, the gallbladder is stimulated to empty the bile into the small intestine. The bile dissolves the fat, making the body able to absorb the nutrients in the food.
Like everything, this is all good until it isnāt! About 10% of us will get stones in our gallbladder [1]. The stones are caused by the precipitation of bile salts, cholesterol and pigments. Most of the time gallstones donāt cause a problem [2]. However, if they prevent the drainage of bile from the gallbladder then this can make the gallbladder inflamed and painful. Fortunately less than 10% of patients who are found to have gallstones will need surgery [3]. In the worstcase scenario, the gallbladder can rupture. Gallstones do this if they block the flow of bile from the gallbladder. This can happen at the bottom of the gallbladder or in the bile duct itself. The most common symptom is said to be pain in the right upper abdomen, lasting more than an hour, known medically as ābiliary colicā. However, patients with gallstones frequently get pain around the back of the rib cage and even up into the right shoulder blade. These symptoms are not even mentioned in the 2014 review of gallstones in 2014 [4] Some of these patients come to chiropractors complaining of āback painā or āpain in the right shoulderā. Itās easy for us to go charging off in the wrong direction, assuming that the pain is a muscular or an articular one
When patients come and see their chiropractor, complaining of pain around the right shoulder, or in the right side of the ribcage. We need to remember to examine the patientās abdomen, the right upper abdominal quadrant, in particular. If this area is tender, then it is often worth having a look at the gallbladder with ultrasound. Gallstones are usually reasonably straightforward to see, even for practitioners who are not radiologists [5] (who would have thought it)! The video that accompanies this blog post demonstrates a gallstone.
The gallbladder is easier to visualise if the patient has not eaten, as it is easier to find when it is full of bile. If there are stones, then a bright reflective line is seen, with quite distinctive shadowing. Gallstones vary hugely in size and shape. Sometimes they are single, often multiple, and occasionally we will see a large collection of small stones.
If the gallstones are causing the gallbladder to be inflamed (cholecystitis), then the gallbladder will often be enlarged (>8cm long and >4cm wide), there will be thickening of the gallbladder wall (>4mm) and there will be fluid around the gallbladder.
Patients with pain in the back and the right shoulder blade often seek help from chiropractors and physiotherapists. If this pain is relieved with manual therapy, all well and good. If not then an ultrasound scan of the abdomenmakes sense, to see whether gallstones may be causing the problem. If that is the case, and if the patient continues to get pain, or if the pain is recurrent, then then a surgical opinion may be necessary with a view to having the gallbladder removed, an operation called a cholecystectomy. Fortunately this is only necessary in less than 10% of patients who have gallstones [3]. Surgery is not recommended in patients who have gallstones but no symptoms [6].
It used to be taught that gallstones were more commonly found in middle-aged overweight females, but increasingly gallstones are found to be present in male patients and patients of all ages.
Patients will often ask if there is any diet that can help to resolve gallstones or make them less likely to cause problems. This is tricky to answer, because although being overweight and eating a high calorie diet increases the likelihood of gallstones, rapid weight loss can also be a trigger for gallstones. Being sedentary and eating a high carbohydrate diet are also both factors that can cause symptomatic gallstones. To my knowledge, no special diet has been demonstrated to resolve gallstones. A recent study [7] has shown that 20 minutes of physical activity daily will reduce the risk of gallbladder problems by 20%.
What can we take from this?
Pain in the right shoulder blade or round the bottom right part of the ribcage may be caused by gallstones. If the pain is recurrent, then ultrasound examination of the gallbladder may be helpful.
Patients who have problems that reduce their mobility are at greater risk of getting gallbladder pain.
If you know anything about Doc Cheng or his drink, please do let me know. I canāt seem to find anything about the product or the man on the internet
1. Kratzer, W., R.A. Mason, and V. KƤchele, Prevalence of gallstones in sonographic surveys worldwide. J Clin Ultrasound, 1999. 27(1): p. 1-7.
2. Attili, A.F., et al., The natural history of gallstones: the GREPCO experience. The GREPCO Group. Hepatology, 1995. 21(3): p. 655-60.
3. Halldestam, I., et al., Development of symptoms and complications in individuals with asymptomatic gallstones. Br J Surg, 2004. 91(6): p. 734-8.
4. Gurusamy, K.S. and B.R. Davidson, Gallstones. BMJ, 2014. 348: p. g2669.
5. Ross, M., et al., Emergency physician-performed ultrasound to diagnose cholelithiasis: a systematic review. Acad Emerg Med. 2011 Mar;18(3):227-35. doi: 10.1111/j.1553-2712.2011.01012.x., 2011.
6. Gurusamy, K.S. and K. Samraj, Cholecystectomy versus no cholecystectomy in patients with silent gallstones. Cochrane Database Syst Rev. 2007 Jan 24;2007(1):CD006230. doi: 10.1002/14651858.CD006230.pub2., 2007.
7. Watts, E.L., et al., Association of Accelerometer-Measured Physical Activity Level With Risks of Hospitalization for 25 Common Health Conditions in UK Adults. JAMA Network Open, 2023. 6(2): p. e2256186-e2256186.
