What is the treatment for a hyperactive gallbladder?

Treatment for Hyperactive Gallbladder

Cholecystectomy is the recommended treatment for symptomatic hyperactive gallbladder (also known as gallbladder dyskinesia or functional gallbladder disorder) when patients experience typical biliary pain. 1

Diagnosis and Clinical Presentation

• Hyperactive gallbladder (gallbladder dyskinesia) is characterized by episodic upper abdominal pain similar to biliary colic but without evidence of gallstones 2
• Typical symptoms include severe epigastric and/or right upper quadrant pain that:
  • Has a relatively abrupt onset (often awakening patients from sleep)
  • Is steady in intensity
  • May radiate to the upper back
  • Is often associated with nausea
  • Lasts for hours up to a day 2
• Dyspeptic symptoms (indigestion, belching, bloating, abdominal discomfort) may be present but are often unrelated to gallbladder function 2, 3

Diagnostic Evaluation

• Cholecystokinin-cholescintigraphy (CCK-CS) is the standard test to diagnose gallbladder dyskinesia 1
• The test measures gallbladder ejection fraction (GBEF) after stimulation with cholecystokinin (CCK)
• An abnormal GBEF (typically <40%) in a patient with biliary-type pain suggests gallbladder dyskinesia 1
• Patient selection impacts test results - patients should meet Rome III criteria for functional gallbladder disorder to increase diagnostic accuracy 1

Treatment Algorithm

1. First-line treatment: Cholecystectomy

   • For patients with typical biliary pain and abnormal GBEF on CCK-CS 1
   • Laparoscopic cholecystectomy is generally preferred over open cholecystectomy due to reduced recovery time 1
   • Studies show that 82-90% of patients with gallbladder dyskinesia experience resolution of symptoms after cholecystectomy 3

2. Conservative management options (for patients who are poor surgical candidates or prefer non-surgical approaches):

   • Dietary modifications:
     • Avoid fatty foods, refined sugars, and other potential dietary triggers 4
     • Consider identifying and avoiding food allergens that may exacerbate symptoms 4
   • Medications that may help reduce gallbladder hyperactivity:
     • Anticholinergics (such as atropine)
     • Calcium channel blockers (such as nifedipine)
     • Somatostatin analogs 5

3. Experimental approaches (limited evidence):

   • Plant terpenes (Rowachol) have shown some success in improving gallbladder function 4
   • Nutritional supplements like vitamin C, soy lecithin may help improve gallbladder health 4

Important Considerations

• Surgical expertise is crucial when performing laparoscopic cholecystectomy to minimize the risk of bile duct injury 1
• Patients should be informed that while cholecystectomy is highly effective for biliary pain (90% success), some dyspeptic symptoms may persist after surgery in approximately 18% of patients 3
• Obesity is associated with fatty infiltration of the gallbladder (cholecystosteatosis), which can lead to decreased contractility and symptoms similar to gallbladder dyskinesia 6
• Patients with atypical symptoms should undergo thorough evaluation to exclude other causes of abdominal pain before proceeding with cholecystectomy 1

Caveats and Pitfalls

• Avoid diagnosing gallbladder dyskinesia in patients with vague, non-specific abdominal symptoms that don't fit the pattern of biliary pain 2
• Ensure proper CCK-CS technique (appropriate dose and infusion rate of CCK) to avoid false-positive results 1
• Patients with psychological distress and prolonged history of dyspeptic symptoms before diagnosis are more likely to have persistent symptoms after cholecystectomy 2
• Treatment should not be delayed in patients with acute cholecystitis or other gallbladder complications, as these require prompt intervention 1