Abdominal pain after eating is a frequent complaint and is caused by multiple diseases among which reflux of acidic stomach contents into the esophagus and gallbladder disorders are the two most common conditions.  Confusion between these two conditions is easy because gallbladder disorders may cause or worsen acid reflux and may partially respond to acid reflux therapy.

         In making the diagnosis, symptoms are more important than laboratory or x-ray findings because many patients who have gallstones have no symptoms and require no treatment while many patients who do not have gallstones do have symptoms and do require treatment.  The decision to treat and the choice of treatment are eminently dependent on the good judgment of the physician in charge.

         Typical symptoms include upper abdominal pain, bloating, cramps, and nausea, all of which tend to subside when patients stop eating and to escalate after eating is resumed.  The more fatty the food and the greater the amount eaten, the more severe the symptoms tend to become.  The pain usually localizes around the stomach and gallbladder areas, which are in the mid-upper and right-upper abdomen, and is often referred to the right shoulder and back.  Vomiting does not occur unless the attack is severe; nocturnal attacks are quite common especially after a late heavy meal.  The attacks tend to be recurrent, stereotypical, and can have serious complications.

         The most feared complications of gallbladder attacks are: a) inflammation of the bile ducts within the liver (cholangitis), which may lead to obstruction and jaundice and b) inflammation of the pancreas (pancreatitis), which can cause necrosis of the tissues surrounding the pancreas.  These severe complications occur usually after multiple warnings but may also present with the initial attack.

         The investigation of the attacks involves liver and pancreas blood tests plus ultrasound and scan of the gallbladder.  During the attack, the liver and pancreas enzymes may become elevated and tenderness in the right upper abdomen may be sharply increased by the examiner’s palpating hand.  The ultrasound may show stones or sludge and the scan may reveal that the gallbladder is no longer able to squeeze out its bile contents.

         The diagnosis is made based on the combination of symptoms, blood tests, ultrasound findings, and scan results.  Clinical judgment, which takes into consideration all these variables, decides on the best course of treatment for each individual patient.  If all the variables are positive, then surgical (laparoscopic) removal of the gallbladder is usually chosen.  If, however, the ultrasound does not reveal stones, the blood tests are normal, and only the scan is positive, then medical therapies are usually tried first.

         Medical therapies include reducing dietary fat, taking cholesterol-lowering medicines (statins), and taking bear bile acid tablets (ursodiol), all of which reduce the amount of cholesterol crystals in the bile ducts and gallbladder.  The bile acts as a detergent, which dissolves the cholesterol made by the liver after it is excreted into the bile ducts.  When the balance between bile and cholesterol is tilted in favor of precipitation instead of dissolution, cholesterol crystals form in the bile ducts and, while the bile is being stored in the gallbladder, these crystals turn into cholesterol stones.  It is this abnormal crystallization of cholesterol that is responsible for the so-called gallbladder attacks.

         Cholesterol lowering medicines (statins) reduce the manufacturing of cholesterol by the liver, which reduces the amount of cholesterol secreted into the bile ducts.  Bear bile acid tablets (ursodiol) increase the amount of bile acids in the bile, which increases cholesterol dissolution.  A low fat diet reduces the amount of cholesterol that the liver makes and excretes into the bile.  When bile cholesterol is reduced or bile acids are increased, the balance is tipped in favor of cholesterol dissolution instead of precipitation and less cholesterol crystals are formed. 

Removing the gallbladder increases the amount of bile flowing into the bile ducts, which increases cholesterol dissolution and reduces crystals.  In spite of that, about 25% of patients may continue to have symptoms after their gallbladder is removed and may require additional medical therapy for full recovery.  In such cases, either the cholesterol lowering medicines (statins) or the bear bile acid tablets (ursodiol) or a combination of the two may be required to tip the balance in favor of cholesterol dissolution instead of crystallization. 

Based of my own research (POST CHOLECYSTECTOMY BILIARY PAIN AND DYSPEPSIA; RESPONSE TO 3-HYDROXY-3METHYLGLUTARYL COENZYME A REDUCTASE INHIBITORS. J OKLA STATE MED ASSOC 1994, 87: 31518.) I favor the use of cholesterol lowering medicines first because they tend to work quickly and seldom have adverse effects.  Most patients who need these medicines do not have high blood cholesterol, perhaps because they are effectively excreting all their excess cholesterol into the bile ducts where it turns into crystals.