What is the management approach for patients with a high gallbladder ejection fraction (EF)?

Management of Patients with High Gallbladder Ejection Fraction

Patients with biliary symptoms and a high gallbladder ejection fraction (EF >80%) should be considered for laparoscopic cholecystectomy, as this can lead to significant symptomatic relief in approximately 75-85% of cases. 1, 2, 3

Diagnostic Criteria and Evaluation

• Biliary hyperkinesia is defined as a gallbladder ejection fraction (EF) greater than 80-81% on cholecystokinin (CCK)-stimulated hepatobiliary iminodiacetic acid (HIDA) scan in patients with biliary symptoms 2
• Patients typically present with:
  • Postprandial right upper quadrant pain (biliary colic) 4, 1
  • Nausea and vomiting (present in approximately 64% of cases) 3
  • Chronic diarrhea (present in approximately 31% of cases) 3
• Initial evaluation should include:
  • Normal abdominal ultrasound (absence of gallstones, sludge, or gallbladder wall thickening) 1
  • CCK-HIDA scan showing elevated EF (>80%) 1, 2, 3
  • Reproduction of symptoms during CCK infusion (occurs in approximately 75% of patients) 1

Treatment Approach

• Laparoscopic cholecystectomy is the recommended treatment for patients with biliary symptoms and high gallbladder EF (>80%) 1, 2, 3
• Expected outcomes after cholecystectomy:
  • Complete symptom resolution: 61-85% of patients 1, 3
  • Partial symptom improvement: 15% of patients 1, 3
  • Overall improvement rate (complete or partial): 76-94% of patients 1, 3

Prognostic Factors

• Higher gallbladder ejection fraction is associated with better outcomes:
  • Patients with complete symptom resolution had a median EF of 94% compared to 88% in those without complete resolution 3
  • An EF cutoff of 81% is significantly associated with pain resolution after cholecystectomy (78.2% for EF ≥81% vs 60.0% for EF <81%) 2
• Pathological findings:
  • Chronic cholecystitis is found in 61-73% of specimens despite normal imaging 1, 2, 3
  • Other findings include cholesterolosis (22%) and polyps (3.4%) 1

Clinical Considerations and Caveats

• Biliary hyperkinesia is a relatively uncommon condition, representing approximately 2.8% of all cholecystectomy cases 1
• The concept of biliary hyperkinesia is still evolving, with less literature available compared to hypokinetic biliary dyskinesia (EF <40%) 4, 5, 3
• Patients should be informed that while success rates are good, approximately 15-24% may not experience complete symptom resolution 1, 3
• The presence of unexpected pathologic findings in 94% of specimens supports the biological basis for this condition 1

Follow-up

• Patients should be evaluated at 2 weeks post-surgery for initial assessment of symptom improvement 1
• Long-term follow-up (10-16 months) is recommended to assess durability of symptom relief 1

While biliary hyperkinesia is less established than hypokinetic biliary dyskinesia as an indication for cholecystectomy, emerging evidence supports surgical intervention in carefully selected patients with typical biliary symptoms and high gallbladder ejection fraction.