Pressure under the right ribs: bile, liver and gallstones
A feeling of pressure in the upper right abdomen makes many people think of the gallbladder. What makes a real biliary colic, what “thick bile” means medically, and which other causes are more common.
How solid is the research? Trust score 3 of 5:Promising
How gallstones form and when they are operated on is well supported by guidelines. The main uncertainty is the grey area: dull pressure without stones, a “sluggish” gallbladder and biliary sludge. Here the evidence is weak, and the symptoms often come from other sources.
Cause or consequence? Root cause 4 of 5:Often a cause
Bile and liver sit under the right ribs, and trouble there usually comes from these two organs, rarely from cartilage or nerves. Stones come from your make-up and diet and are where the chain starts: they lead to biliary colic and often to removal of the gallbladder.
Healthy state
Under the right ribs lie the liver and gallbladder, along with the duodenum, the right bend of the colon and, further back, the right kidney. The gallbladder is a small store beneath the liver. Between meals it collects bile, removes water from it and concentrates it strongly in the process.
When fat or protein arrives in the duodenum, the gut wall releases the hormone CCK (cholecystokinin) A hormone from the duodenum. It is released in response to fat and protein, makes the gallbladder contract and calls up digestive enzymes from the pancreas. More in the chapter “The digestive chain: how stomach acid, bile and pancreas set each other off”. The gallbladder contracts and releases its contents. The Bile acids Substances made by the liver that make fat digestible. About 95 percent are reabsorbed in the last part of the small intestine; gut bacteria transform the rest. More in the chapter “Bile acids: when bile causes diarrhoea” in it make fat soluble for digestion. Afterwards the gallbladder fills up again. This regular emptying keeps the bile moving.
Bile is a finely balanced solution of bile acids, Lecithin A mixture of choline phospholipids, obtained from soy or sunflower. In bile it keeps cholesterol dissolved; as a capsule for fat digestion it is not proven. More in the chapter “Bile, lipase and lecithin: what fat digestion really needs” and cholesterol. As long as there are enough bile acids and lecithin, the cholesterol stays dissolved. If the ratio gets out of balance, crystals form.
A real biliary colic has a typical pattern: severe, steady pain in the upper abdomen or on the right under the ribs that lasts at least 15 to 30 minutes, often radiates to the back or the right shoulder and does not improve by changing position or opening the bowels. It often comes in the evening or at night, sometimes after a high-fat meal.
Disrupted state: causes and effects
Gallstones are very common: in Europe, about one in ten to one in five adults has them. Most notice nothing. In a large US study of more than 22,000 people with stones found by chance, around 10 per cent developed symptoms within five years and around 21 per cent within ten years, so about 2 per cent per year. Women, younger people and people with many or large stones were more likely to be affected.
“Thick bile” has a medical name: biliary sludge. These are fine crystals of cholesterol or calcium salts that appear on ultrasound as sediment in the gallbladder. They form mainly when the gallbladder rarely empties: in pregnancy, with rapid weight loss, with prolonged fasting or with intravenous feeding. Sludge can disappear on its own, come and go or turn into stones, and it can cause the same problems as stones.
Rapid weight loss is a known trigger: the liver releases more cholesterol into the bile, and on a very low-fat diet the gallbladder hardly contracts. In studies, the bile acid medicine Ursodeoxycholic acid A bile acid used as a medicine, prescription-only in many countries. Approved among other things for dissolving gallstones and for certain liver diseases. More in the chapter “Bile, lipase and lecithin: what fat digestion really needs” and a diet with a little more fat reduced the risk of new stones during weight loss.
A dull, constant pressure or bloated feeling in the upper right, by contrast, is not a typical sign of gallstones. More common causes are a sensitive stomach and a fatty liver stretching the liver capsule. If stones are found by chance, they often do not explain such symptoms, and the symptoms then persist after surgery.
For colic-like pain without stones there is the diagnosis of functional gallbladder disorder. It is disputed. A Meta-analysis An analysis that combines the results of several studies. It is only as good as the studies it includes. found that people with normal and with reduced gallbladder emptying improved equally often after surgery, which points to a Placebo A dummy treatment without an active ingredient. Comparing with it shows how much a remedy achieves beyond expectation and chance. effect.
Emergency signs are fever with pain in the upper right, yellowing of the skin or eyes, dark urine with pale stools, pain that does not ease, or severe pain radiating to the back with vomiting. These may be due to inflammation of the gallbladder, a stone in the bile duct or inflammation of the pancreas.
Where it comes from and where it leads
The same symptoms can have different roots. This map shows what may be involved in this problem and what may follow from it.
Possible causes. . Possible consequences. No gallbladder, Abdominal pain, Bile acids, Nutrient deficiency, Food fear, Digestive chain, Weak digestion, SIBO, Diarrhoea, Brain fog & fatigue
- Possible causes
- This problem
- Possible consequences
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Move the mouse over a box: its connections are highlighted and everything else steps back.
Tap a box to highlight its connections. Tap it again to open the chapter.
Connections, not certainty: a link means “can”, not “must”. What applies to you is best clarified in a talk with your doctor.
What often helps
Lifestyle
Diet, exercise, sleep, social contact and dealing with stress.
- Exercise In a large observational study of more than 45,000 men, among those under 65 the most active had a risk of gallstone symptoms around 40 per cent lower than the least active, beyond the benefit for weight. A lot of sitting went along with more symptoms. Promising How we rate the evidence Established Recommended in medical guidelines or supported by several consistent meta-analyses of randomised human studies. Well supported Several randomised studies in humans with largely consistent results. Promising Single randomised or controlled studies in humans, not yet independently confirmed — or many consistent observational studies. Plausible Two cases: first observational or pilot studies with small samples — or a settled basis that is not in dispute, such as movement, sleep or meal pauses. But not tested in humans for symptoms. Experimental Barely studied in humans. Mainly lab and animal studies or theoretical reasoning; whether it helps is open. [1]
- Lose weight slowly, not completely fat-free If you want to lose a lot of weight, it is better to do it gradually. A small amount of fat per meal makes sure the gallbladder empties regularly. In studies, higher-fat weight-loss diets reduced stone formation compared with very low-fat ones. With very rapid weight loss or after stomach surgery, ursodeoxycholic acid can be useful as prevention; your doctor decides. Well supported How we rate the evidence Established Recommended in medical guidelines or supported by several consistent meta-analyses of randomised human studies. Well supported Several randomised studies in humans with largely consistent results. Promising Single randomised or controlled studies in humans, not yet independently confirmed — or many consistent observational studies. Plausible Two cases: first observational or pilot studies with small samples — or a settled basis that is not in dispute, such as movement, sleep or meal pauses. But not tested in humans for symptoms. Experimental Barely studied in humans. Mainly lab and animal studies or theoretical reasoning; whether it helps is open. [2][3]
- Coffee In a Danish study of more than 100,000 people, more coffee went along with fewer gallstone symptoms, and a genetic analysis supported a causal link. This is no reason to drink coffee, but also none to avoid it for the sake of the gallbladder. Plausible How we rate the evidence Established Recommended in medical guidelines or supported by several consistent meta-analyses of randomised human studies. Well supported Several randomised studies in humans with largely consistent results. Promising Single randomised or controlled studies in humans, not yet independently confirmed — or many consistent observational studies. Plausible Two cases: first observational or pilot studies with small samples — or a settled basis that is not in dispute, such as movement, sleep or meal pauses. But not tested in humans for symptoms. Experimental Barely studied in humans. Mainly lab and animal studies or theoretical reasoning; whether it helps is open. [4]
Natural supplements
Supplements do not replace a medical check-up. Discuss dosage and interactions with your doctor or pharmacist.
- Liver and gallbladder flush with oil After oil cleanses with olive oil and lemon juice, greenish “stones” appear in the stool. A lab examined such objects: they consisted of fatty acids, a kind of soap made from the oil itself, without cholesterol or bile pigment. Real stones are not flushed out this way, and if stones are present, strong stimulation of the gallbladder can trigger a colic. Experimental How we rate the evidence Established Recommended in medical guidelines or supported by several consistent meta-analyses of randomised human studies. Well supported Several randomised studies in humans with largely consistent results. Promising Single randomised or controlled studies in humans, not yet independently confirmed — or many consistent observational studies. Plausible Two cases: first observational or pilot studies with small samples — or a settled basis that is not in dispute, such as movement, sleep or meal pauses. But not tested in humans for symptoms. Experimental Barely studied in humans. Mainly lab and animal studies or theoretical reasoning; whether it helps is open. [5]
Medical treatments
Information, not a treatment recommendation. Decide together with a doctor. Approval and availability differ from country to country.
- Ultrasound as the first step Stones, sludge, a thickened gallbladder wall and a fatty liver can be seen well on ultrasound. Blood tests for liver, bile and pancreas are added. This is quick, painless and without radiation. Established How we rate the evidence Established Recommended in medical guidelines or supported by several consistent meta-analyses of randomised human studies. Well supported Several randomised studies in humans with largely consistent results. Promising Single randomised or controlled studies in humans, not yet independently confirmed — or many consistent observational studies. Plausible Two cases: first observational or pilot studies with small samples — or a settled basis that is not in dispute, such as movement, sleep or meal pauses. But not tested in humans for symptoms. Experimental Barely studied in humans. Mainly lab and animal studies or theoretical reasoning; whether it helps is open. [6]
- Surgery for real colic, not for silent stones For stones with typical colic or complications, guidelines recommend removing the gallbladder, usually by keyhole surgery. For stones found by chance without symptoms, the usual approach is to wait, because most never cause problems. Established How we rate the evidence Established Recommended in medical guidelines or supported by several consistent meta-analyses of randomised human studies. Well supported Several randomised studies in humans with largely consistent results. Promising Single randomised or controlled studies in humans, not yet independently confirmed — or many consistent observational studies. Plausible Two cases: first observational or pilot studies with small samples — or a settled basis that is not in dispute, such as movement, sleep or meal pauses. But not tested in humans for symptoms. Experimental Barely studied in humans. Mainly lab and animal studies or theoretical reasoning; whether it helps is open. [6][7]
- Ursodeoxycholic acid only for selected cases It can slowly dissolve small cholesterol stones in a well-functioning gallbladder and prevents new stones during rapid weight loss. The evidence for treating colic pain is thin. After stopping, stones often form again. Promising How we rate the evidence Established Recommended in medical guidelines or supported by several consistent meta-analyses of randomised human studies. Well supported Several randomised studies in humans with largely consistent results. Promising Single randomised or controlled studies in humans, not yet independently confirmed — or many consistent observational studies. Plausible Two cases: first observational or pilot studies with small samples — or a settled basis that is not in dispute, such as movement, sleep or meal pauses. But not tested in humans for symptoms. Experimental Barely studied in humans. Mainly lab and animal studies or theoretical reasoning; whether it helps is open. [8][2]
- Use gallbladder function tests with caution A nuclear medicine test measures how strongly the gallbladder empties. Whether a low value justifies surgery is not established. Before surgery without stones, it is worth thoroughly checking other causes and getting a second opinion. Plausible How we rate the evidence Established Recommended in medical guidelines or supported by several consistent meta-analyses of randomised human studies. Well supported Several randomised studies in humans with largely consistent results. Promising Single randomised or controlled studies in humans, not yet independently confirmed — or many consistent observational studies. Plausible Two cases: first observational or pilot studies with small samples — or a settled basis that is not in dispute, such as movement, sleep or meal pauses. But not tested in humans for symptoms. Experimental Barely studied in humans. Mainly lab and animal studies or theoretical reasoning; whether it helps is open. [9][10]
From the community: what people report
Experiences and tips from people with the same problems that come up again and again, but for which there are no meaningful studies yet. They are explicitly not evidence.
The "liver and gallbladder cleanse" with oil and Epsom salt
Very many report that with oil, Epsom salt and citrus or fruit juice they passed "stones", sometimes dozens, and felt better afterwards. Other patients counter that these green lumps are not gallstones but form from the oil – medical bodies say the same, and some patient forums now ban advertising the cleanse. Important: such a large amount of fat together with Epsom salt can trigger biliary colic or inflammation of the pancreas and bile ducts; with symptoms, self-treatment is risky because a stuck stone can become life-threatening.
Pain without stones – and the gallbladder ejection fraction
Many report cramp-like pain under the right ribcage even though ultrasound shows no stones. Again and again a gallbladder function test comes up that yields a notably high or low ejection fraction; after removal of the gallbladder, some clearly improved, others did not. It is often reported that nothing was found at first and that patients were only taken seriously after several attempts.
Stones after rapid weight loss or a low-fat diet
Again and again patients report that their gallstones formed during a phase of rapid weight loss or a very low-fat diet. In forums this is often set against the widespread advice to eat low-fat precisely to prevent attacks; the two are discussed as a contradiction. It is also often reported that attacks come with no recognizable trigger at all.
Personal reports can mislead: what helps many people may be a placebo, and what helps one may harm another. Treat them as ideas to raise with your doctor or pharmacist – not as instructions.
In the mood for something completely different? Another one, at random
How we rate the evidence
- Trust score 5 of 5:Established
- Recommended in medical guidelines or supported by several consistent meta-analyses of randomised human studies.
- Trust score 4 of 5:Well supported
- Several randomised studies in humans with largely consistent results.
- Trust score 3 of 5:Promising
- Single randomised or controlled studies in humans, not yet independently confirmed — or many consistent observational studies.
- Trust score 2 of 5:Plausible
- Two cases: first observational or pilot studies with small samples — or a settled basis that is not in dispute, such as movement, sleep or meal pauses. But not tested in humans for symptoms.
- Trust score 1 of 5:Experimental
- Barely studied in humans. Mainly lab and animal studies or theoretical reasoning; whether it helps is open.
Sources
- Leitzmann et al. 1998: Physical activity and gallstone symptoms in men (Annals of Internal Medicine)
- Stokes et al. 2014: Ursodeoxycholic acid and higher-fat diets prevent gallstones during weight loss, meta-analysis (Clinical Gastroenterology and Hepatology)
- Shiffman et al. 1995: gallstones on a very-low-calorie diet and prevention with ursodeoxycholic acid (Annals of Internal Medicine)
- Nordestgaard et al. 2020: Coffee and gallstones, Mendelian randomisation (Journal of Internal Medicine)
- Sies and Brooker 2005: “Could these be gallstones?”, analysis of “stones” after an oil cleanse (Lancet)
- EASL 2016: European guideline on the prevention, diagnosis and treatment of gallstones (Journal of Hepatology)
- Morris-Stiff et al. 2023: Natural course of silent gallstones, 22,257 people (Clinical Gastroenterology and Hepatology)
- Hall et al. 2023: Ursodeoxycholic acid for gallstone symptoms, systematic review (BJS Open)
- Gudsoorkar et al. 2019: Surgery for gallbladder dysfunction, meta-analysis (Alimentary Pharmacology & Therapeutics)
- Cotton et al. 2016: Rome IV, gallbladder and sphincter disorders (Gastroenterology)
- Pazzi et al. 2003: Biliary sludge, review (Digestive and Liver Disease)
- EASL, EASD and EASO 2024: Guideline on fatty liver disease (MASLD) (Journal of Hepatology)
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