cholelithiasis presented as chronic right back pain in the case discussed in this report . according to the clinical practice guidelines , gallbladder lithiasis is a common condition . around two - thirds of the cases
are asymptomatic , with the most frequent clinical presentation being the presence of attacks of acute abdominal pain . however , chronic right back pain persisting for months as a main symptom is uncommon .
this report presents a patient with right back and subscapular pain for 9 months , demonstrating both biliary lithiasis and chronic cholecystitis .
it is important to take into account the atypical manifestations of a prevalent illness as well as the limitations of the diagnostic tests , since the presence of gallstones can easily be missed or misinterpreted and delay in diagnosis may lead to complications which could worsen the prognosis of the patient .
a 47-year - old male presented with a history of chronic neck pain that had started 10 years back .
he underwent a magnetic resonance ( mr ) which showed cervical canal stenosis of degenerative etiology and also had an episode to self - limited abdominal spasmodic pain that appeared 10 years ago , considered as being functional by the gastroenterologist .
abdominal ultrasonography was performed twice , and both times it was normal . one and a half years ago , the patient had right subscapular and paralumbar back pain at the t10l2 level for 9 months .
he described it as a permanent pain , which persisted throughout the day , with very intense exacerbations , especially in the evening and at night .
these exacerbations usually lasted for 4 - 6 h , worsening on inhalation and sometimes radiating to subcostal and right hemithorax .
the only feature of note on physical examination was the palpation of painful spinal processes from t10 to l2 .
blood analysis showed the level of gamma - glutamyl traspeptidase to be 79 u / l , while all the other laboratory parameters were normal .
abdominal computed tomography ( ct ) showed an extensive hepatic steatosis and a moderately relaxed gallbladder , with no stones observed within thin walls [ figure 1 ] .
abdominal ct : gallbladder without gallstones despite the regular use of analgesics and the rehabilitation treatment that followed , the patient presented a torpid evolution . due to the pain in the right paralumbar area ,
an abdominal ultrasonography was performed , which showed moderate hepatic steatosis and a gallbladder with multiple inner calculi [ figure 2 ] .
on diagnosis of cholelithiasis , a cholecystectomy was carried out , which revealed a gallbladder with a large number of yellow lithiasic structures , thereby confirming an anatomopathological diagnosis of chronic cholecystitis [ figure 3 ] .
the previous pain completely disappeared after surgery and the patient remained asymptomatic 7 months later .
back pain affects 80% of adults at some point of their life and occurs at all ages .
the first objective is to rule out a visceral disorder or a serious potentially life - threatening condition , which occurs in 2.7% of the cases
. back pain may be the manifestation of thoracic involvement as in esophageal disease , pleurisy , aortic aneurysm , or coronary heart disease , or an abdominal process , such as gastrointestinal ulcer , gastric cancer , pancreatic cancer , pancreatitis , or biliary pathology .
only one - third of the cases of gallstones are symptomatic and give an indication for surgery .
the most frequent symptomatic manifestation is episodic upper abdominal pain called biliary colic , with complications such as cholecystitis , acute pancreatitis , cholangitis , or choledocholithiasis being less frequent .
characteristically , this pain is severe and located in the epigastrium and/or the right upper quadrant .
the pain may radiate to the upper back or the right scapula in 60% of the cases and might be associated with nausea or vomiting , usually occurring in the late evening or at night , in 80% of the cases .
one study carried out to characterize the presentation in cholelithiasis reported that all patients described pain in the right upper quadrant of the abdomen , including the epigastrium .
the pain was located in the right subcostal area ( 20% ) and epigastrium ( 14% ) , which radiated to the back in 63% .
in fact , chronic cholecystitis is thought to be a result of a delay in diagnosis .
the test of choice to diagnose cholelithiasis is transabdominal ultrasound , with a sensitivity and specificity greater than 95% for detecting gallstones larger than 4 mm .
abdominal ct scan has a very low sensitivity and gallstones may be visible due to most being isodense .
microlithiasis ( stones <3 mm in diameter ) is not detectable by transabdominal ultrasonography ; however , it may cause complications such as acute pancreatitis . in some patients
the diagnosis can be confirmed by the detection of biliary crystals by microscopic examination of bile collected from the duodenum . in patients with a clinical history of biliary colic with negative transabdominal ultrasonography ,
endoscopic ultrasonography is an important diagnostic tool , since it can detect microlithiasis in a proportion of patients ranging from 41 to 78% .
patients with pain and a negative abdominal ultrasound show an endoscopic ultrasound and/or a positive analysis of the bile .
most of these patients show positive results on cholecystectomy , with resolution of abdominal pain and improvement in their quality of life .
non - vertebral causes such as the presence of gallstones should be considered in patients with back pain .
physicians should be aware of atypical manifestations of common diseases , so as to avoid diagnostic delays .
gallbladder disorders should be taken into account in patients with dull , undefined right back pain , despite a normal physical examination .
abdominal ultrasound should be chosen as the first diagnostic procedure when considering gallstones , since ct scans have a very low sensitivity for their detection . in a patient with a typical clinical report of biliary colic and a negative abdominal ultrasound ,
this was the case of our patient in whom the abdominal ultrasonography was normal 5 years earlier , thereby making correct differential diagnosis crucial .
 chronic right back pain is a symptom in both biliary lithiasis and chronic cholecystitis 
 . ten percent of the population in the world suffers from biliary lithiasis . 
 only 20% are symptomatic . 
 the first diagnostic test of choice is an abdominal ultrasound . 
 when a suggestive clinical sign of biliary colic with negative abdominal ultrasound is identified , we should consider the option of carrying out an endoscopic ultrasound in order to rule out microlithiasis . 
 the case discussed in the report presented with chronic right back pain , which is an atypical manifestation of biliary lithiasis and chronic cholecystitis . 
 it is important to know about the atypical manifestations of the prevalent illnesses as well as the limits of the diagnostic tests , in order to avoid diagnostic delays which may cause complications that could worsen a patient 's prognosis . 
 this case should contribute to the medical knowledge and must have educational value or highlight the need for a change in clinical practice , especially in primary care . 