What is the appropriate treatment for biliary dyskinesia presenting with recurrent right‑upper‑quadrant or epigastric abdominal pain?

Treatment for Biliary Dyskinesia with Abdominal Pain

Laparoscopic cholecystectomy is the definitive treatment for biliary dyskinesia presenting with recurrent right upper quadrant or epigastric pain when gallbladder ejection fraction is less than 35% on CCK-HIDA scan, with symptom resolution rates of 58.8-98%. 1, 2

Diagnostic Confirmation Before Treatment

Before proceeding to treatment, confirm the diagnosis through a structured algorithm:

• Start with right upper quadrant ultrasound to exclude gallstones, as biliary dyskinesia is defined by typical biliary pain in the absence of cholelithiasis 3, 1
• Obtain liver function tests to rule out other hepatobiliary pathology 4
• Perform CCK-HIDA scan (cholecystokinin-cholescintigraphy) to measure gallbladder ejection fraction—this is the diagnostic test of choice for biliary dyskinesia 4, 1, 5
• An ejection fraction less than 35-40% is diagnostic of biliary dyskinesia and indicates impaired gallbladder emptying 1, 5, 2

Surgical Treatment: Laparoscopic Cholecystectomy

Cholecystectomy is indicated when biliary dyskinesia is confirmed (EF <35%) and patients meet Rome IV criteria for functional gallbladder disorder (recurrent biliary pain lasting ≥30 minutes, located in epigastrium or right upper quadrant, often triggered by fatty foods). 1, 5

Expected Outcomes

• Symptom relief occurs in 58.8-98% of patients after laparoscopic cholecystectomy for confirmed biliary dyskinesia 1, 2
• The majority of prospective studies, although small, support cholecystectomy as effective treatment for adult biliary dyskinesia 5
• Patients with type I sphincter of Oddi dysfunction (≥90%) benefit from endoscopic biliary sphincterotomy if dyskinesia persists post-cholecystectomy 1

Special Populations and Emerging Considerations

Normokinetic or Hyperkinetic Gallbladder (EF >35-80%)

A subset of patients present with typical biliary pain but normal (35-80%) or elevated (>80%) ejection fractions:

• Patients with EF >35% who experience reproducible pain during CCK infusion on HIDA scan may have "normokinetic biliary dyskinesia" 6
• Complete symptom resolution occurred in 89.5% of these patients after cholecystectomy in one retrospective series 6
• Patients with hyperkinetic gallbladder (EF >80%) had 100% symptom improvement after cholecystectomy in a small cohort (2 patients), though data remain limited 2
• Consider cholecystectomy in patients with typical biliary symptoms and reproducible pain on CCK-HIDA, even when EF is normal or elevated, after excluding other causes of right upper quadrant pain 7, 6

Pediatric Population

• Biliary dyskinesia is now the number one indication for cholecystectomy in children, despite insufficient high-quality data supporting this practice 5
• The same diagnostic criteria apply (typical biliary pain, negative ultrasound, low EF on CCK-HIDA), but evidence for surgical benefit in pediatrics is weaker than in adults 5

Critical Pitfalls and Caveats

Diagnostic Variability

• CCK-HIDA protocols vary significantly among institutions, leading to inconsistent and poorly reproducible results 5
• Despite Society of Nuclear Medicine guidelines, lack of standardization affects the reliability of ejection fraction measurements 5
• Short follow-up intervals and nonstandardized outcome definitions in most studies limit the strength of evidence 5

When NOT to Operate

• Do not proceed to cholecystectomy without first ruling out choledocholithiasis, sphincter of Oddi dysfunction, peptic ulcer disease, gastroesophageal reflux, and other causes of right upper quadrant pain 4, 1
• If initial ultrasound and CCK-HIDA are equivocal, obtain MRCP to comprehensively evaluate the biliary tree and exclude structural abnormalities 4
• Consider empiric trial of proton pump inhibitor therapy (omeprazole 20-40 mg daily for 4-8 weeks) before surgery if gastroduodenal pathology is suspected 4

Post-Cholecystectomy Considerations

• If biliary pain persists after cholecystectomy, consider sphincter of Oddi dysfunction, which may require sphincter of Oddi manometry and endoscopic sphincterotomy 1
• MRCP is the preferred imaging modality for evaluating post-cholecystectomy pain, with sensitivity of 85-100% for detecting retained stones or biliary strictures 8, 4

Algorithm Summary

1. Confirm typical biliary pain (Rome IV criteria: episodic right upper quadrant/epigastric pain lasting ≥30 minutes, often postprandial)
2. Ultrasound abdomen to exclude gallstones 3, 1
3. Liver function tests to exclude other hepatobiliary disease 4
4. CCK-HIDA scan to measure gallbladder ejection fraction 1, 5
5. If EF <35%: Refer for laparoscopic cholecystectomy 1, 5, 2
6. If EF 35-80% or >80% with reproducible pain on CCK infusion: Consider cholecystectomy after excluding other diagnoses 7, 6, 2
7. If symptoms persist post-cholecystectomy: Evaluate for sphincter of Oddi dysfunction with MRCP or manometry 8, 1