What could cause recurrent right‑sided abdominal pain with intermittent dizziness despite normal imaging studies?

Recurrent Right-Sided Abdominal Pain with Dizziness and Normal Imaging

Your recurrent right-sided abdominal pain with normal imaging most likely represents a functional gallbladder disorder (biliary dyskinesia or hyperkinesia) or a disorder of gut-brain interaction, and you should request a HIDA scan with gallbladder ejection fraction measurement as the next diagnostic step. 1, 2

Why Your Scans May Have Missed the Diagnosis

Standard imaging (ultrasound and CT) can miss functional gallbladder disorders because they only detect structural abnormalities like stones or inflammation, not abnormal gallbladder function. 1, 2

• HIDA scan with cholecystokinin stimulation is specifically designed to measure how your gallbladder contracts and empties, revealing functional problems that don't show up on routine imaging. 1
• A gallbladder ejection fraction below 35% indicates biliary dyskinesia (sluggish gallbladder), while an ejection fraction above 80% indicates biliary hyperkinesia (overactive gallbladder)—both can cause your exact symptoms. 2
• Recent case reports demonstrate that patients with intermittent right-sided pain and normal ultrasound who undergo HIDA scanning often have abnormal ejection fractions, and laparoscopic cholecystectomy provides complete symptom resolution. 2

The Dizziness Component

Your dizziness likely represents vasovagal response to visceral pain rather than a separate pathology. 3

• Severe abdominal pain can trigger autonomic nervous system responses causing lightheadedness, near-syncope, and dizziness without actual loss of consciousness. 3
• This is particularly common with biliary colic, where intense cramping pain triggers vagal stimulation. 2

Critical Next Steps in Your Workup

Request these specific tests from your doctor:

• HIDA scan with CCK (cholecystokinin) stimulation to measure gallbladder ejection fraction—this is the single most important test you haven't had yet. 1, 2
• Provocation test: Ask your doctor if eating a fatty meal reproduces your pain within 30-60 minutes, which strongly suggests gallbladder dysfunction. 2
• If HIDA scan is normal, consider upper endoscopy to rule out peptic ulcer disease or gastritis, which CT has relatively low sensitivity for detecting (only 64% negative predictive value for upper abdominal pathology). 3

What Else Could This Be?

If the HIDA scan is normal, consider these functional disorders that cause identical symptoms:

• Functional dyspepsia or irritable bowel syndrome affects approximately 1 in 4 people and causes recurrent abdominal pain with normal imaging. 4
• Sphincter of Oddi dysfunction causes intermittent right upper quadrant pain and can be evaluated with CCK-augmented HIDA scanning. 1
• Chronic cholecystitis may show subtle findings on MRI with MRCP that were missed on CT, particularly gallbladder wall thickening with low T2 signal. 1

Red Flags That Would Change the Approach

Seek immediate evaluation if you develop any of these:

• Fever with severe pain (suggests infection, abscess, or perforation). 3
• Rigid abdomen or rebound tenderness (indicates perforation or ischemia). 3
• Pain out of proportion to physical findings (strongly suggests mesenteric ischemia). 3
• Hemodynamic instability like rapid heart rate or low blood pressure (suggests bleeding or sepsis). 3

Common Pitfalls to Avoid

• Don't accept "everything is normal" without functional testing. Standard imaging only detects structural disease, not the functional disorders that cause 25% of chronic abdominal pain. 4
• Don't dismiss the pain as "just stress" or "functional" without completing the HIDA scan workup first. Biliary hyperkinesia is a real, treatable condition that resolves with cholecystectomy. 2
• Don't start opioid pain medications. If this turns out to be a functional disorder, opioids worsen outcomes and should never be used for chronic functional abdominal pain. 1, 4

If HIDA Scan Shows Abnormal Ejection Fraction

Laparoscopic cholecystectomy should be strongly considered, as it provides significant symptom relief in patients with functional gallbladder disorders and recurrent biliary colic. 2

• Surgery is particularly appropriate when pain significantly impairs your quality of life, which appears to be your situation given the recurrent nature and associated dizziness. 2
• Success rates for symptom resolution after cholecystectomy in patients with abnormal HIDA scans are high, especially when pain is reproducible with fatty meals. 2

If All Testing Remains Normal

Consider referral to a gastroenterologist specializing in disorders of gut-brain interaction for:

• Gut-directed hypnotherapy or cognitive behavioral therapy, which have strong evidence for reducing chronic gastrointestinal pain. 1
• Neuromodulators (tricyclic antidepressants ranked first for abdominal pain relief in functional disorders, not opioids). 1
• Avoid the trap of endless testing—if comprehensive evaluation including HIDA scan is normal, shifting to a pain management approach rather than continued diagnostic pursuit is appropriate. 1, 4