Management of Gallbladder Dysfunction
For patients with functional gallbladder dysfunction (biliary dyskinesia), cholecystectomy should be offered when there is documented biliary-type pain with either an abnormally low gallbladder ejection fraction (<35%) on CCK-HIDA scan or pain reproduction during CCK administration, though success rates are lower than for gallstone disease. 1, 2
Diagnostic Criteria and Patient Selection
The diagnosis of gallbladder dysfunction requires careful evaluation to distinguish it from other causes of abdominal pain:
Biliary-type pain characteristics must be present: episodic pain in the epigastrium or right upper quadrant, lasting 30 minutes or longer, severe enough to interrupt daily activities, and not significantly related to bowel movements or postural changes 2, 3
Cholecystokinin-enhanced hepatobiliary scintigraphy (CCK-HIDA scan) is the primary diagnostic test, with a gallbladder ejection fraction <35% considered abnormal 1, 3
Pain reproduction during CCK administration during the HIDA scan is an important additional criterion that may predict better surgical outcomes 1
Exclusion of gallstones and other structural abnormalities is mandatory through transabdominal ultrasound before considering functional gallbladder disorder 4, 5
Treatment Algorithm
When Surgery IS Indicated
Laparoscopic cholecystectomy is the definitive treatment for confirmed functional gallbladder disorder, but patient selection is critical:
Patients with both abnormal ejection fraction (<35%) AND reproduction of typical pain during CCK administration have the highest likelihood of symptom resolution 1
The Critical View of Safety technique must be employed during surgery to minimize bile duct injury risk 4, 6
Success rates are significantly lower than for gallstone disease: only 85% of patients experience relief following cholecystectomy for gallbladder dysfunction, compared to nearly 100% for symptomatic cholelithiasis 1
When Surgery Should Be Avoided
Patients with atypical dyspeptic symptoms (bloating, nausea, food intolerance) rather than true biliary colic are less likely to benefit from cholecystectomy 4
CCK-cholescintigraphy does not add value beyond clinical judgment alone in predicting surgical outcomes for patients with atypical symptoms 4
The Rome IV criteria have discarded the concept of sphincter of Oddi dysfunction type III (post-cholecystectomy pain without objective abnormalities), as sphincterotomy is no better than sham treatment in this population 2
Critical Pitfalls and Caveats
The most important caveat is the high rate of persistent symptoms post-operatively:
Up to 15% of patients will continue to have symptoms after cholecystectomy for functional gallbladder disorder, a rate much higher than for gallstone disease 1
Post-cholecystectomy syndrome can occur with symptoms including abdominal pain, bloating, diarrhea, and dyspepsia 4
The fluctuating nature of symptoms and significant placebo effect of invasive interventions make evaluation challenging 2
There is a pressing need for prospective studies to provide better guidance, as current evidence is limited and controversial 1, 2
Alternative Considerations
For patients who are poor surgical candidates or decline surgery:
Expectant management with symptom monitoring is reasonable, as the natural history of functional gallbladder disorder is not well-defined and complications are rare 2, 3
Medical therapy with ursodiol is not indicated for functional gallbladder disorder, as it only works for cholesterol gallstone dissolution 7
ERCP and sphincterotomy have no role in functional gallbladder disorder without documented sphincter of Oddi abnormalities 2
The decision to proceed with cholecystectomy must weigh the 85% success rate against the 15% risk of persistent symptoms and surgical complications, making thorough patient counseling essential before proceeding 1