Usually, the major muscular and big organ located in the right upper quadrant of the abdomen is the liver and many junior clinicians in their early clinical experience tend to describe this kind of pain as an origin from the liver related illnesses.  

In one of my clinical practice, a 46-year-old post-menopausal mother was referred to me for evaluation a with one-and-a-half years history of intermittent, dull, stubby right upper quadrant pain associated with nausea sensation but no vomiting. Pain was postprandial.  

This pain could last for at least 45 minutes in a gradual and progressive manner and often radiated towards the shoulder blades. It was not associated with exercise or any other stimulant. The patient had no history of fever, chills, change of urine or stool colour as well as jaundice.

She also had no history of abundant alcoholism. The patient reported that sometimes pain could be exaggerated and could not perform well her daily duties.

I had an impression of an ongoing chronic illness based on her clinical presentation and duration of her complaints that had lasted for over a year. 

We took laboratory tests for her. We focussed on the biochemistry profile that included liver enzymes, alkaline phosphatase, amylase, bilirubin and lipase.

Based on the patient information, even her previous biochemistry profile tests were persistently normal. 

We booked her an ultra-sound exam, and the right upper quadrant ultrasound showed a normal gallbladder appearance with no gallstones. 

The intra-hepatic and extra-hepatic bile ducts were not dilated. The liver and pancreas contours were in regular shape. Even the esophago-gastro-duodenoscopy turned to be normal. 

When we consulted one of the physicians, who revealed that the characteristic presentation of the disease was suggestive of biliary origin. 

He pointed out that the pain syndrome accompanied by normal gallbladder ultrasound and normal liver function tests is always suggestive of calculus gallbladder disease. 

However, when such patients are encountered other causes for right upper quadrant pain need to be considered and reasonably excluded. 

Such diseases include choledocholithiasis, microlithiasis, pancreatobiliary neoplasia, peptic ulcer disease, irritable bowel syndrome and musculoskeletal pain. 

Another possible diagnosis is the type III sphincter of Oddi dysfunction but because of the risks of endoscopic retrograde cholangio-pancreatography, gallbladder evaluation is usually undertaken first. 

Although ultrasound and magnetic resonance cholangiopancreatography have relatively high sensitivity rates for the detection of common bile duct stones, small stones and microlithiasis might be missed. 

Endoscopic ultrasound and microscopic bile examination for microlithiasis might be useful in a subset of these patients.

There is current contradiction in the patho-physiology of acalculous gallbladder pain. 

There are theories that implicate gallbladder outlet obstruction where as there are those that point at a primary disorder of gallbladder motility, and those that implicate visceral hypersensitivity. 

But most importantly is that lack of coordination between gallbladder contraction and contractions of the sphincter of Oddi or relative cystic duct narrowing might cause functional gallbladder obstruction.

 Abnormal gallbladder motility might occur because of entrapment of over saturated cholesterol crystals in the gallbladder wall. 

Visceral hypersensitivity might play a role in acalculous biliary pain (biliary dyskinesia) analogous to that in other functional disorders of the gastrointestinal tract.

The most prominent symptom of biliary dyskinesia is right upper quadrant pain. For this, characteristic biliary pain is intermittent, often radiates to the right shoulder or back, is frequently associated with nausea and vomiting.

 It has no association with posture, exercise, or bowel movements. Jaundice and fever are usually not present. Physical examination is usually unremarkable except for mild right upper quadrant tenderness but also rare. This evidence is in line with clinical complaints that were presented by the patient and further re-affirm our biliary calculus disease diagnosis.  

A cholecystectomy or surgical intervention is often recommended. This treatment is usually accompanied by antibiotics and analgesics. 

Dr Joseph Kamugisha is a resident oncologist in Jerusalem, Israel