Yes, significant gallbladder pain can occur even when imaging shows no evidence of gallstones. This condition is termed acalculous biliary disease, which means “without stones,” presenting with symptoms—known as biliary pain or biliary colic—that are virtually identical to those caused by a physical obstruction. The gallbladder stores and concentrates bile produced by the liver, releasing it into the small intestine after a meal. When this process fails, pressure builds up in the gallbladder and bile ducts, causing the characteristic pain.
Understanding Pain Without Stones (Acalculous Disease)
The most common cause of chronic gallbladder pain without stones is Biliary Dyskinesia, meaning “abnormal movement” of the gallbladder. In this functional disorder, the muscular wall fails to contract with sufficient force to empty the stored bile effectively. This sluggish contraction causes bile to back up, leading to severe, episodic pain typically felt in the upper right abdomen, often radiating to the back or shoulder. The pain mimics a stone blockage because the underlying issue is pressure increase caused by muscular malfunction rather than a solid object.
Biliary Dyskinesia is categorized as a hypokinetic disorder, meaning the gallbladder is “lazy” and exhibits a low Ejection Fraction (EF). Pain occurs because the gallbladder cannot empty properly after a meal, especially a fatty one. A less common functional issue, Sphincter of Oddi Dysfunction (SOD), can also cause similar pain. SOD involves the muscular valve controlling the flow of bile and pancreatic juices into the small intestine. When this sphincter muscle spasms or fails to relax, it causes a backup of digestive fluids, creating biliary pain even though the gallbladder is structurally normal.
Acalculous Cholecystitis represents an acute situation where gallbladder inflammation occurs without stones. This condition is far less common than chronic functional issues and is usually seen in critically ill patients suffering from severe medical events. Trauma, burns, sepsis, or prolonged fasting can impair blood flow to the gallbladder, leading to stasis and inflammation. Unlike chronic Biliary Dyskinesia, acute acalculous cholecystitis is a severe, life-threatening condition requiring immediate medical attention.
Diagnostic Confirmation of Functional Disorder
Diagnosis for non-stone gallbladder pain begins by ruling out common causes of abdominal distress, such as ulcers or pancreatitis. An abdominal ultrasound is the first step, confirming the absence of gallstones and checking for inflammation or duct dilation. Blood tests are performed to ensure there is no acute infection or elevated liver and pancreas enzymes. The diagnosis of a functional disorder is often one of exclusion, requiring a thorough evaluation to eliminate other possible gastrointestinal causes.
The definitive test for diagnosing Biliary Dyskinesia is the Hepatobiliary Iminodiacetic Acid (HIDA) scan, sometimes performed with Cholecystokinin (CCK) stimulation. The HIDA scan uses a radioactive tracer to track the flow of bile from the liver through the gallbladder and into the small intestine. During the test, synthetic CCK is administered to stimulate the gallbladder to contract, mimicking the effect of a fatty meal. The key measurement is the Gallbladder Ejection Fraction (EF), which quantifies the percentage of bile the organ expels.
A low EF demonstrates the organ’s inability to contract adequately, serving as proof of functional gallbladder disorder. Experts define an abnormal EF as less than 35% when the test uses a standardized, slow infusion of CCK. Reproduction of the patient’s typical pain during CCK infusion, combined with a low EF, is highly suggestive of Biliary Dyskinesia. This combination of symptoms and objective functional data confirms the acalculous disease diagnosis.
Treatment Pathways for Non-Stone Gallbladder Pain
Once Biliary Dyskinesia is confirmed by a low Gallbladder Ejection Fraction, the primary treatment is surgical removal of the gallbladder, known as a cholecystectomy. For patients with mild or intermittent symptoms, a temporary trial of conservative management, including a low-fat diet, may be attempted. However, because the underlying issue is a functional muscular problem, conservative measures rarely offer a long-term solution.
Laparoscopic cholecystectomy, a minimally invasive procedure, is the standard of care for confirmed Biliary Dyskinesia. This surgery eliminates the source of the pain by removing the poorly contracting organ that causes pressure buildup. Studies indicate that for patients who meet the established diagnostic criteria, including a low EF on the HIDA scan, the surgery offers a high rate of success, with symptom relief reported in approximately 90% of cases. Removing the gallbladder allows bile to flow directly from the liver to the small intestine, bypassing the dysfunctional organ and resolving the pressure-related pain.