Can ulcer pain be distinguished from gallstone pain?

Question

When referred to a gastroenterologist for intermittent pain in the upper right quadrant of the abdomen (slightly under the rib cage), my friend was told that she probably had an ulcer and the doctor needed to do an endoscopy to confirm.

My friend has gone to two doctors so far regarding intermittent but intense pain in the upper right quadrant of her abdomen (slightly under the rib cage). Her GP considered it to be possibly gallstones and referred her to a gastroenterologist to get an ultrasound and further treatment. The gastroenterologist, however, thought it was most likely an ulcer and that he would need to do an endoscopy.

I'm not looking for an internet diagnosis for her :) Her primary concern is that an ultrasound is less expensive and doesn't involve sedation or require a day of fasting, and she wonders whether the gastroenterologist has chosen a less likely avenue to pursue since he would get paid much more for it. To that end, she wants to know what symptoms can distinguish the two conditions, and potentially consult another specialist before undergoing an endoscopy.

These are the symptoms we think we know:

• Symptoms of gallbladder issues (1, 2, 3, 4)

  • Pain in upper right abdomen
  • Hurts when you push on it
  • Nausea/vomiting
  • Constipation, diarrhea, burping, bloating/gas

• Symptoms of stomach ulcer (1, 2)

  • Pain in upper central abdomen
  • Pain goes away with antacids (n/a in her case)
  • Nausea/vomiting
  • Burping, bloating

Beyond the symptoms, the risk factors appear to be really different:

• gallstones: fat, female (true), high-fat low-fiber diet (true-ish, diet isn't that bad), diabetes, 60+ (n/a)
• ulcer: smoke, drink, frequent NSAID use, old (n/a)

Answer 1

Even a gastroenterologist may not be able to reliable differentiate between the stomach ulcer and gallstone pain just from history/physical examination.

This is typical (but not obligatory):

Gallstone pain:

• Sudden onset of pain in the upper part of the right abdominal quadrant, just below the lowest rib and about 4 inches from the sternal line (or more broadly in the upper right quadrant or in the upper middle abdomen)
• The pain builds up to a steady level and remains constant and lasts from several minutes to few hours.
• The pain is typically associated with nausea (or vomiting): when the pain subsides, nausea also subsides.
• The pain can (not necessary) radiate around the trunk to the lower right back and into the tip of the right shoulder blade.
• The pain is not relieved by antacids or having a bowel movement.
• Source: Gallbladder pain (eHealthStar.com)

Stomach ulcer pain: (the ulcer can be in the stomach or duodenum)

• Burning, gnawing pain in the upper middle abdomen - below the bottom of the sternum or slightly to the left or right
• Pain is relieved by antacids (long-term, H2 blockers or PP inhibitors would help).
• Black stools (from a bleeding ulcer)
• Nausea or vomiting can be present or not - more likely when the cause is an infection by H. pylori.
• The stomach area may or may not be tender to touch.
• Source: Stomach (gastric) ulcer (Patient.info)

NOT typical:

• Burping, bloating, gas, constipation and loose stools can be present but are not typical for gallstones or stomach ulcer as such.
• A large fatty meal can trigger gallstone pain, but the pain can be totally non-related to meals, for example, it can occur at night.
• The gallbladder area may or may not be tender to touch. In case of acute gallbladder inflammation, a patient could feel pain during an inspiration when a doctor presses to the gallbladder area (Murphy's sign - short video).
• Food can either ease or aggravate ulcer pain.
• Risk factors have some statistical value, but young, slim women and those on a low-fat--or any--diet can get gallstones. Also, non-smokers, non-drinkers and non-NSAIDs users can get an ulcer.

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Strong indicators for an ulcer: black stools, pain relieved by antacids, positive H. pylori test

Strong indicators for gallstones: pain in the upper right abdominal quadrant + lower right back + right shoulder blade