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Journal of Case Reports
Gall Stones Presenting as Left Lumbar Pain: A Rare Occurrence
BC Shah, Sarang Degloorkar, A Rao
Department of Surgery, Bhakti Vedanta Hospital and Research Institute, Srishti Complex, Mira Road East, Thane, Maharashtra-401017, India.
Corresponding Author:
Dr. BC Shah
Email: vaishnavasevadasa@gmail.com
Received: 12-OCT-2014 Accepted: 23-NOV-2014 Published Online: 10-JAN-2015
DOI: http://dx.doi.org/10.17659/01.2015.0004
Abstract
Gallstones occur commonly in Indian population. Gallstones are typically associated with  right upper abdominal pain which increase in intensity following fat meal and are associated with nausea. We present here a rare case of gall stones  presenting with atypical location of the pain.
Keywords : Cholelithiasis, Gallstones, Pain, Abdominal pain, Nausea, Humans.
Introduction

Gallstones are common surgical problem and the patients usually remain asymptomatic. Symptomatic individuals present with colicky right upper abdominal pain aggravated following the ingestion of fat rich diet, often associated with nausea rarely vomiting. When patients present with left lumbar pain, the differential diagnoses include renal colic, herpes zoster and pleuritis. We encountered a case of gallstone presenting with left lumbar pain. Considering the rarity of the presentation, we are reporting this as a case report. 

Case Report

A 49 year old female presented with sudden onset pain in the left lumbar region for the past 8 hours. The pain was constant, non-colicky, dull aching in nature accompanied with nausea. No history of any disturbance in the bowel or bladder habits was reported. She is a mother of two and both the pregnancies were through normal delivery. Physical examination revealed no signs in the abdomen. Ultrasound abdomen showed the presence of few mobile calculi in gallbladder. Liver function tests, urine macroscopic and microscopic examination were normal. A provisional diagnosis of asymptomatic gall bladder stones with renal pain mostly due to undetected renal calculi was made. The patient was managed conservatively with the advice of plenty of fluid intake and analgesics. The patient presented again after two months with the complaint of severe left lumbar pain. A computed tomography scan of the abdomen revealed multiple gall bladder calculi (a mobile calculus of 16 mm in size and two others measuring 4-5 mm and 7 mm in fundus) without any evidence of cholecystitis, rest of CT scan findings were in normal limits.

    Patient was reassured since no major cause was identified.  She kept on complaining for pain for more than 2 weeks. The patient had regular pain in the same region i.e. left lumbar; every night following food intake. Hence, it was decided to perform diagnostic laparoscopy with cholecystectomy. Patient was explained the diagnostic dilemma and after obtaining the consent from the patient, a diagnostic laparoscopy was carried out. The laparoscopy showed normal bowel, pelvic organs, retroperitoneum. There was no evidence of any other pathology within abdomen. After confirming normalcy of abdomen, cholecystectomy was performed. Gall bladder appeared grossly normal with no evidence of chronic cholecystitis or adhesions. On follow up patient immediately became pain free. The patient has remained pain-free for the past two years since surgery. Hence, there is a strong possibility that the gall stones were responsible for the left lumbar pain in this case, which is very uncommon. The fact that patient had post prandial pain and was relieved by surgery suggests that pain was due to gall stones.


Discussion

Gallstones are a common surgical problem occurring at a prevalence of around 4% in the Indian population [1]. A geographic difference is also observed, the condition being more common in North Indian belt than South. Certain factors that have been found to be high risk for developing gallstones include female gender, increasing age, family history, rapid changes in body weight, ethnicity and pregnancy [2]. Most of the patients with gallstone remain asymptomatic but around 6% undergo surgery [3]. Pain due to gallstones present typically as a colicky right upper abdominal pain aggravated following the ingestion of fat rich diet, often associated with nausea rarely vomiting. Physical examination may reveal tenderness in the right upper quadrant associated with rebound and guarding. A positive Murphy sign (inspiratory arrest on deep palpation of the right upper quadrant during deep inspiration) is highly suggestive of cholecystitis albeit being non-specific.

    The underlying mechanisms which contributed to development of left lumbar pain in cholecystitis are difficult to explain as it is unusual to have left lumbar pain in cholecystitis. However, it can be a referred pain which is pain perceived distant from its source and results from convergence of nerve fibers at the spinal cord. Common examples of referred pain are scapular pain due to biliary colic, groin pain due to renal colic, and shoulder pain due to blood or infection irritating the diaphragm.

    We have presented here this case due to its rare presentation that has never been documented in the literature. Hence, gallstones shall be considered as one of the uncommon cause for left lumbar abdominal pain. Textbooks do mention that differential diagnosis of left sided  lumbar pain can be  cholelithiasis.

Conclusion

Diagnosis of abdominal pain can be very challenging in rare cases where pathology is on one side and patient reports pain on opposite side. This occurs due to differential innervation.

References
  1. Unisa S, Jagannath P, Dhir V, Khandelwal C, Sarangi L, Roy TK. Population-based study to estimate prevalence and determine risk factors of gall bladder diseases in the rural Gangetic basin of North India. Hepatobiliary Disease. 2011;13:117-125.
  2. Jayanthi V, Palanivelu C, Prasanthi R, Methew S, Srinivasan V. Composition of gallstones in Coimbator district of Tamilnadu state. Ind J Gastroenterol. 1998;17:134-135.
  3. Dalal S, Pankaj, Bhoriwal S, Kumar R, Sujata. Giant Gallstone: A Rare Indication of Open Cholecystectomy. Journal of Case Reports. 2014;4(1):17-19.
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Shah BC, Degloorkar S, Rao AGall Stones Presenting as Left Lumbar Pain: A Rare Occurrence.JCR 2015;5:13-15
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Shah BC, Degloorkar S, Rao AGall Stones Presenting as Left Lumbar Pain: A Rare Occurrence.JCR [serial online] 2015[cited 2018 Jul 19];5:13-15. Available from: http://www.casereports.in/articles/5/1/Gall-Stones-Presenting-as-Left-Lumbar-Pain.html
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