What is the initial management for a hyperkinetic gallbladder?

Management of Hyperkinetic Gallbladder

Laparoscopic cholecystectomy is the recommended initial management for symptomatic hyperkinetic gallbladder (ejection fraction ≥80% on HIDA scan), as it provides symptom resolution in over 90% of patients. 1, 2

Definition and Diagnosis

• Hyperkinetic gallbladder, also known as biliary hyperkinesia, is defined as a gallbladder ejection fraction (GBEF) ≥80% on cholecystokinin-hepatobiliary iminodiacetic acid (CCK-HIDA) scan 1, 2
• This condition is often underdiagnosed and underrecognized, with many radiologists reporting these findings as "normal" rather than hyperkinetic 1
• Patients typically present with right upper quadrant pain similar to biliary colic, often accompanied by nausea and vomiting 3, 4

Diagnostic Approach

• Ultrasound should be performed as the initial imaging study to rule out cholelithiasis and other structural abnormalities 5
• CCK-HIDA scan is the definitive test for diagnosing hyperkinetic gallbladder 5
• Reproduction of symptoms during CCK infusion supports the diagnosis and predicts better outcomes after cholecystectomy 2
• Magnetic resonance cholangiopancreatography (MRCP) may be considered if common bile duct stones are suspected 5

Treatment Algorithm

First-line Management:

• Laparoscopic cholecystectomy is the treatment of choice for symptomatic hyperkinetic gallbladder 1, 2, 3
  • Provides symptom resolution in 93-96% of patients 1, 6
  • Particularly effective when symptoms are reproduced during CCK infusion 2

Patient Selection Criteria:

• Right upper quadrant pain consistent with biliary colic 3, 4
• GBEF ≥80% on CCK-HIDA scan 1, 2
• Absence of other clear etiology for symptoms 3
• Higher ejection fractions (>90%) may predict better outcomes after surgery 4

Pathophysiology and Outcomes

• Chronic cholecystitis is found in 68-83% of hyperkinetic gallbladders on pathology examination after cholecystectomy 1, 2, 4
• Cholelithiasis may be present in approximately 39% of cases despite negative preoperative imaging 1
• Patients with persistent symptoms after cholecystectomy often have other chronic gastrointestinal conditions 1

Important Considerations and Caveats

• Hyperkinetic gallbladder is underreported by radiologists, with only 13.7% of HIDA scans with EF≥80% being correctly identified as hyperkinetic 1
• Patients should be evaluated for other gastrointestinal conditions that may contribute to symptoms 1, 6
• The median time from HIDA scan to cholecystectomy in clinical practice is approximately 146 days, suggesting potential delays in diagnosis and treatment 1
• Patients with higher ejection fractions (>90%) may have better outcomes after cholecystectomy compared to those with ejection fractions between 80-90% 4

Non-surgical Management

• Non-surgical management is associated with higher rates of emergency department visits, medication use, and persistent symptoms compared to cholecystectomy 6
• Patients managed non-operatively often receive alternative diagnoses and have higher symptom scores on standardized assessment tools 6