From the Guidelines
Gallbladder disease can still be present despite a normal ultrasound, and further testing is recommended if symptoms suggest gallbladder pathology. If symptoms persist, such as right upper quadrant pain, especially after fatty meals, consider a HIDA scan to evaluate gallbladder function and ejection fraction, which can identify functional disorders like biliary dyskinesia 1. The use of cholecystokinin-augmented nuclear medicine hepatobiliary imaging in patients with pain of biliary origin is an acceptable practice under current Society of Gastrointestinal and Laparoendoscopic Surgeons clinical guidelines 1.
Diagnostic Approach
- Consider a HIDA scan to evaluate gallbladder function and ejection fraction
- Endoscopic ultrasound may detect small stones missed by conventional ultrasound
- MRI with MRCP (magnetic resonance cholangiopancreatography) can visualize the biliary tree and identify subtle abnormalities
Treatment Approach
- For persistent symptoms, empiric treatment with ursodeoxycholic acid (300-600mg daily in divided doses) may help dissolve small stones or improve bile flow
- Dietary modifications including reduced fat intake and small, frequent meals can help manage symptoms
- If symptoms persist and functional gallbladder disease is confirmed, cholecystectomy may ultimately be necessary even with a normal ultrasound 1. The disconnect between imaging and symptoms occurs because functional disorders affect gallbladder contraction and bile flow without creating visible structural abnormalities on basic imaging. CT may reveal such complications as gangrene, gas formation, intraluminal hemorrhage, and perforation, and can be used as a next step if US or scintigraphy are negative for acute cholecystitis and there is no alternative diagnosis 1.
From the Research
Gallbladder Disease with Normal Ultrasound
- Gallbladder disease can present with various symptoms, including right upper quadrant pain, and can be diagnosed using imaging modalities such as ultrasound, CT, and MRI 2, 3.
- Ultrasound is the initial imaging modality of choice for evaluating patients with suspected gallbladder disease, including those with symptoms of gallstone disease 4, 5.
- However, a normal ultrasound does not necessarily rule out gallbladder disease, as some conditions such as adenomyomatosis or gallbladder polyps can mimic gallbladder malignancies or acute cholecystitis 2, 3.
- In cases where ultrasound findings are negative or equivocal, further imaging modalities such as HIDA scan or MRCP can be used to evaluate for cholecystitis or other complications of gallstone disease 4.
- The management of symptomatic gallstone disease can include treatment with nonsteroidal anti-inflammatory drugs, laparoscopic cholecystectomy, or other surgical interventions, as well as the use of bile acids such as ursodeoxycholic acid in certain cases 4, 6.
Diagnostic Challenges
- The diagnosis of gallbladder disease can be challenging, and accurate imaging assessment is crucial to avoid potential pitfalls and misdiagnosis 3.
- The use of multiple imaging modalities and a thorough clinical evaluation can help to improve diagnostic accuracy and guide appropriate management 2, 3, 4.
- Further research is needed to better understand the role of different imaging modalities and treatments in the management of gallbladder disease, particularly in cases with normal ultrasound findings 6.