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Dynamic Chiropractic – July 15, 1994, Vol. 12, Issue 15

Primary Care: Recurrent Shoulder Pain, Could It Be Biliary Stones?

By Raymond Nanko, DC, MD
We as physicians often focus on what we want to see, instead of
analyzing each piece of the clinical puzzle. Frequently, we
encounter new patients with diffuse unilateral recurrent shoulder
pain, absent of any traumatic or significant history. Immediately
we tune out any organic etiology and readily welcome a
musculoskeletal diagnosis. We attach an overuse syndrome or a
myofascial pain syndrome diagnosis when no joint pathology or
fixation is detected.

The patient undergoes chiropractic care and over time receives
symptomatic relief. However, after discontinuing her care the
shoulder and backache continue. Further investigation may have
revealed that she may suffer abdominal discomfort after fatty
meals, runs an intermittent low grade temperature and her stools
now have changed to a lighter color. This is the typical
presentation of cholelithiasis, nonspecific complaints which unless
a thorough review of systems is undertaken will not be detected.

Cholelithiasis or biliary stones are the most common cause of
biliary tract disease in the United States. It is estimated the
occurrence is 20 to 35 percent of all American-born people by the
age of 75 years. Biliary stones are made predominately of two
major types; the majority of biliary stones are formed of
cholesterol and make up approximately 75 percent of the total,
whereas pigment stones are composed of calcium bilrubinate salts
account for approximately 25 percent.

The pathogenesis of biliary stones is incompletely understood.
Factors which may be lithogenic or stone forming include:
increased cholesterol saturation, as occurs with increased estrogen
levels; obesity; oral contraceptive pills (which decrease the bile
acid pool); and certain inflammatory bowel diseases affecting the
terminal ilium. Biliary stasis secondary to bile duct strictures,
choledochal cysts, TPN, and prolonged fasting diets may also lead
to stone formation.

The majority of patients with biliary stones are asymptomatic and
the stones are usually detected incidentally on spinal x-rays,
abdominal ultrasound, and CT/MRI examinations for other diagnostic
reasons. The clinical features are more prevalent in a group
characterized by the four "Fs." The four "Fs" include female sex
(higher levels of estrogen), fat/obese (fat contains high levels of
estrogen), forty (increased incidence with age), and
fertile/multiparity (levels of estrogen increase during pregnancy
and excess retained weight postpartum). Other features may
include fatty food intolerance and flatulence or excess gas after
meals.

The hallmark of biliary stones is right upper quadrant (RUQ) pain
which typically radiates to the right shoulder or the inferior tip
of the scapula and a history of biliary colic, which is
characterized by intermittent sharp, usually postprandial pain
caused by contraction of the gallbladder contents against a stone
impacted in the cystic duct. The patient may also exhibit a low
grade fever, experience nausea and vomiting, jaundice (minority of
patients), pruritus (itching), dark urine (Coca-cola like), clay
color/light color stools, and have a history of oral contraceptive
pills. These symptoms are the classical presentation of biliary
stones, however, the majority of cases will have little or no
symptoms and patients usually do not contribute these symptoms to
their present condition.

On physical examination, the right upper quadrant may be tender in
the acute patient. The examiner should then try to elicit a
Murphy's sign. Murphy's sign is demonstrated by palpation of the
gall bladder, in which upon deep inspiration the patient
experiences moderate gall bladder tenderness that causes the
patient to suddenly stop their inspiration. In addition, vital
signs should be checked for a low grade temperature and the patient
should be inspected for signs of jaundice.

Clinical laboratory evaluation should be limited to a CBC and liver
function tests with amylase and lipase. The CBC will show a mild
leukoctyosis if the gall bladder is inflamed. The LFTs usually
reveal a moderately elevated alkaline phosphatase and total
bilirubin, whereas SGOT and SGPT will only be mildly elevated.
Amylase and lipase should also be ordered to rule out any
pancreatic involvement, especially if the patient is experiencing
persistent epigastric pain.

Ultrasound of the liver and gallbladder is the diagnostic gold
standard for all liver and biliary disease. It is a safe and
noninvasive procedure, which is readily tolerated by each patient.
The gall bladder, liver parenchyma, pancreatic and common bile
ducts can easily be visualized during ultrasound examination.
Visualization of stones, sludge, thickening of the gall bladder
mucosa and dilatations of the common bile duct, hepatic and
pancreatic ducts all suggest biliary tract disease.

The flat plate abdominal x-ray has a low diagnostic yield. Only
approximately 20 percent of biliary stones contain the calcium
salts which make them radio-opaque, therefore the majority of
biliary stones are not visualized. This is in contrast to kidney
stones which consist primarily of radio-opaque calcium salts and
account for 80 percent of the total. Additional tests such as the
HIDA SCAN (nuclear medicine study) and the MRI/CT scans both have
excellent diagnostic yields, however, they are not cost effective
and are limited to more complicated cases.

Diagnosis of a patient with suspected biliary stones is usually
made by a detailed clinical history, suspicious physical
examination findings, and a diagnostic ultrasound of the gall
bladder. Visualization of stones, sludge, or thickening of the
gall bladder mucosa suggesting chronic inflammation is diagnostic.

Diagnosis of a patient with suspected biliary stones is usually
made by a detailed clinical history, suspicious physical
examination findings, and a diagnostic ultrasound of the gall
bladder. Visualization of stones, sludge, or thickening of the
gall bladder mucosa suggesting chronic inflammation is diagnostic.

Management of the asymptomatic patient should be directed to
patient education and dietary suggestions of low fat meals if the
patient is experiencing fatty food intolerance. The patient should
be instructed further that if he/she should develop symptoms, they
should return to your office for further work-up and evaluation.

In the symptomatic patient, the general rule of thumb for
management is surgery. When the patient becomes symptomatic and
has positive ultrasound findings, i.e., stones, sludge, increased
thickness of the G.B. wall mucosa, he/she should be referred to a
general surgeon to determine the need for an open vs. laproscopic
assisted cholecystectomy.

By 1995, it is projected that 95 percent of all cholecystectomies,
outside medical residency training programs will be performed
through the laproscope. The surgery is slightly more costly,
however, the overall expense is over shadowed by a shorter hospital
stay, less scar tissue, and less disability which allows the
patient to return to work much sooner.

Other nonsurgical treatment options include extracorporeal shock
wave lithotripsy (ESWL). This procedure is used to fragment
biliary stones to permit their passage through the biliary tract.
ESWL is usually performed in combination with oral bile salt agents
for a period of weeks to months. To be considered for ESWL certain
criteria must be met. The stones must be less than three in number
and less than three cm. ESWL usually requires two to four
lithotripsy session to adequately fragment the stones small enough
to pass the fragments out of the biliary tree. Some patients
experience biliary colic with passage of the fragments and usually
elect for surgery during the treatment course. The ESWL procedure
has had great success with kidney stones, but is still
controversial for biliary stones.

Oral bile salt preparations, such as Actigall (ursodeoxycholic
acid), are used in the dissolution of cholesterol stones. They
have no effect on stones which may contain calcium salts and
require continuous therapy over months to years to achieve a 50 to
60 percent success rate. Biliary stones may reoccur anytime after
discontinuing medication, therefore it is not considered cost
effective, and should be limited to patients who are not
adequate surgical candidates.

Summary

Typically, patients with biliary disease do not follow the
classical picture. Therefore it is imperative to adequately assess
each individual patient with a detailed history, including a review
of systems and an extended physical examination, beyond orthopedic
testing. As the doctor of chiropractic incorporates more of
his/her primary care medicine skills, he/she will thoroughly assess
more viscerosomatic etiologies in which he/she will have an impact
on.

As doctors of chiropractic are challenged to treat many disease
processes by alleviating nerve interferences caused by spinal
misalignments, complete recognition and understanding of referred
pain syndromes is essential. The thoroughness of your
investigation will instill greater patient confidence and place the
patient at ease about consulting their DC for all of their health
care needs.

References

Andreoli T et al. Cecil: Essentials of Medicine, 2nd ed.
Philadelphia: W.B. Saunders Company, 1990, pgs. 336-340.

Jaffe PE. Gallstones: Who are good candidates for nonsurgical
treatment? Postgraduate Medicine 1993; Vol 94, No.6, pgs. 45-47.

Woodley M et al. Manual of Medical Therapeutics, 27 ed.
Washington: Litte, Brown Publications, 1992, pg 308.

Raymond S. Nanko, DC, MD
Huntington Beach, California


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