Case02

A 42-year-old is seen by their primary care physician complaining of intermittent colicky pain (sharp, localized gastrointestinal pain that comes in spasms/waves). The patient describes the pain as being right upper quadrant (RUQ), starting shortly after eating a meal, and lasting about 30 minutes. During these episodes, she says she feels bloated and nauseated. The patient also states that over the past 2 days, her stools have become very light in color, like the color of sand, and her skin and eyes have become yellow. They have not experienced these symptoms before.

Question 2/3 - Jaundice patients can often experience referred pain, with the pain referring to which most common location?

Incorrect. McBurney's point is 2/3rd the distance from the umbilicus towards the right anterior superior iliac spine. This is the location for classic appendicitis pain.

Incorrect. Lumbar flank pain is usually observed with referred pain from kidney pain (e.g. kidney stones) and not from gallstone/gallbladder pain.

Correct! The right scapula, specifically the inferior angle region of the scapula, is the most common location for referred gallbladder pain.

While the mechanism is unclear, it is thought to involve phrenic nerve fibers extending inferiorly from the diaphragm in the falciform ligament to the region of the gallbladder. Pain detected in the diaphragm converges to cervical level (C3,4,5) which are also the levels innervating the shoulder and scapula. The brain may be misinterpreting the gallbladder sensory signal to cervical spinal levels as coming from the 'usual' location when pain is sensed at those levels, i.e. pain at the scapula.

Incorrect. The gallbladder is on the right and most referred pain symptoms are unilateral in nature. A left scapula or back pain can be a reference from a left hemi-diaphragm irritation such as a splenic injury.

Incorrect. The left shoulder is a classic location for cardiac pain referencing, not that of gallbladder.