In a patient with recurrent right upper quadrant (RUQ) or epigastric pain, nausea, and no imaging evidence of gallstones, how should biliary dyskinesia be diagnosed and managed?

Biliary Dyskinesia: Diagnosis and Management

Diagnostic Approach

In patients with recurrent right upper quadrant or epigastric pain without gallstones on imaging, biliary dyskinesia should be diagnosed using Rome III criteria combined with cholecystokinin-cholescintigraphy (CCK-CS/HIDA scan), and cholecystectomy should be offered as first-line treatment when the gallbladder ejection fraction is abnormal (<38-40%). 1, 2, 3

Patient Selection Criteria

Before ordering CCK-CS, patients must meet Rome III criteria for functional gallbladder disorder, which requires all of the following: 1

• Episodes of pain in the right upper quadrant and/or epigastrium lasting at least 30 minutes 1
• Recurrent episodes occurring at different intervals (not daily) 1
• Pain builds to a steady level and is severe enough to interrupt activities or prompt a clinic visit 1
• Pain is NOT relieved by bowel movements, postural changes, or antacids 1
• Gallbladder is present and other structural diseases have been excluded 1
• Normal liver enzymes and pancreatic enzymes 1

Supportive features include pain associated with nausea/vomiting, radiation to the back or right infrascapular area, and pain that awakens the patient from sleep. 1

Mandatory Pre-Test Evaluation

Before performing CCK-CS, you must exclude other causes: 1, 4

• Transabdominal ultrasound to rule out gallstones (96% accuracy for stone detection) 1, 4
• Liver function tests (AST, ALT, alkaline phosphatase, bilirubin, GGT) 1, 4
• Pancreatic enzymes (amylase and lipase) to exclude pancreatitis 1, 4
• Upper endoscopy to rule out peptic ulcer disease and other gastroduodenal pathology 1

Critical Pitfall: Avoid Testing Patients with Atypical Symptoms

Do not perform CCK-CS in patients with atypical symptoms, as this increases false-positive rates and leads to unnecessary surgery. 1 Patients with diabetes, celiac disease, irritable bowel syndrome, or those taking opioids, calcium channel blockers, oral contraceptives, H2-blockers, or benzodiazepines may have abnormal ejection fractions without true gallbladder disease. 1

Standardized CCK-Cholescintigraphy Protocol

The test must be performed using a standardized protocol to ensure validity: 1

• Sincalide (CCK) dose: 0.02 μg/kg infused over 60 minutes 1
• Patient should NOT be in pain or hospitalized at the time of testing 1
• Calculate gallbladder ejection fraction (GBEF) 1
• Normal GBEF is >38% 1

Important caveat: Pain provocation during CCK infusion does NOT have proven diagnostic value and should NOT guide treatment decisions. 1 Some patients with normal gallbladders experience transient discomfort with CCK administration. 1

Management Based on Test Results

When GBEF is Abnormal (<38-40%)

Cholecystectomy is the recommended treatment and provides excellent outcomes: 2, 3

• 94-98% of patients experience symptom resolution after cholecystectomy 2, 5, 3
• 84% of surgical specimens show chronic cholecystitis on pathology, confirming true gallbladder disease 2
• Laparoscopic cholecystectomy should be performed early to prevent recurrent pain 4

The most recent high-quality study (2025) demonstrated that all patients with biliary dyskinesia who underwent cholecystectomy experienced complete symptom resolution, and 84% had histologic evidence of chronic cholecystitis. 2 This strongly supports cholecystectomy as first-line treatment rather than prolonged medical workup. 2, 3

When GBEF is Normal or Borderline

If the GBEF is >50% but symptoms are reproduced during CCK infusion, cholecystectomy still provides benefit in 83.4% of patients. 3 However, this scenario requires more careful patient selection and shared decision-making. 3

If both GBEF and symptom reproduction are normal, biliary dyskinesia is unlikely and you should pursue alternative diagnoses including sphincter of Oddi dysfunction, peptic ulcer disease, or functional dyspepsia. 1, 5

Special Considerations

Medications That Interfere with Testing

Ensure patients are not taking medications that impair gallbladder contractility at the time of CCK-CS: 1

• Opioid analgesics 1
• Calcium channel blockers 1
• Oral contraceptives 1
• H2-receptor antagonists 1
• Benzodiazepines 1

Alternative Diagnoses to Consider

If CCK-CS is normal, consider sphincter of Oddi dysfunction, especially in post-cholecystectomy patients with persistent biliary-type pain. 6, 5 This requires specialized evaluation with sphincter of Oddi manometry or therapeutic ERCP in select cases. 6, 5

Evidence Limitations and Future Directions

The current evidence base has significant limitations: 1, 7

• No large randomized controlled trials comparing cholecystectomy versus conservative management exist 1
• Most data comes from retrospective case series 2, 3, 7
• The pathophysiology of functional biliary pain remains poorly understood 1

Despite these limitations, the consistently high success rates (>90%) with cholecystectomy in properly selected patients justify surgical intervention when Rome III criteria are met and GBEF is abnormal. 2, 3 The alternative—prolonged expensive medical testing—is not cost-effective given the excellent surgical outcomes. 3