Gallbladder Dyskinesia: Symptoms, Diagnosis & Treatment

What is gallbladder dyskinesia? (Acalculous cholecystopathy)

Gallbladder dyskinesia, also known as acalculous cholecystopathy or biliary dyskinesia, is a functional disorder of the gallbladder characterised by impaired gallbladder motility in the absence of gallstones. Patients experience typical biliary colic (right upper quadrant pain after fatty meals) but have a normal ultrasound showing no stones, sludge, or wall thickening. The condition is diagnosed by a HIDA scan with cholecystokinin (CCK) stimulation, which measures the gallbladder ejection fraction (EF). An EF of less than 35‑40% is considered abnormal and indicates poor gallbladder contractility. Gallbladder dyskinesia is a recognised cause of chronic abdominal pain and is treated with cholecystectomy.

Causes – functional disorder, not structural

The exact cause of gallbladder dyskinesia is not fully understood. It is thought to result from:

• Functional obstruction of the cystic duct (microscopic or physiologic).
• Abnormal sensitivity of the gallbladder to cholecystokinin (CCK).
• Autonomic neuropathy – more common in diabetics.
• Chronic inflammation without visible stones (mild chronic cholecystitis on pathology).

Risk factors include female sex, age 20‑50, and possibly a history of irritable bowel syndrome (IBS) or functional dyspepsia.

Symptoms – biliary colic without gallstones

Symptoms are identical to those of gallstones but occur in the absence of stones:

• Right upper quadrant or epigastric pain – dull, aching, or colicky.
• Pain triggered by fatty meals – often occurs 30‑60 minutes after eating.
• Pain duration: 15 minutes to several hours.
• Associated nausea, bloating, and fat intolerance.
• No fever, jaundice, or abnormal liver function tests.

Diagnosis – HIDA scan with CCK (ejection fraction <35%)

The gold standard for diagnosing gallbladder dyskinesia is a HIDA scan with cholecystokinin (CCK) stimulation. Steps:

• Patient fasts for 4‑6 hours.
• Radioactive tracer (technetium‑99m) is injected intravenously. It is taken up by the liver and excreted into bile.
• Images are taken to visualise the gallbladder filling.
• Cholecystokinin (CCK) is infused intravenously – this hormone causes the gallbladder to contract.
• Ejection fraction (EF) is calculated: Percentage of tracer emptied from the gallbladder.

Interpretation:

• EF <35%: Abnormal (dyskinesia). Cholecystectomy often provides symptom relief.
• EF 35‑65%: Borderline. Correlation with symptoms is less clear.
• EF >65%: Normal. Gallbladder dyskinesia unlikely.

Additional tests: Upper endoscopy to rule out peptic ulcer, abdominal ultrasound to exclude stones, and possibly CT scan.

Differential diagnosis – rule out other causes of RUQ pain

Before diagnosing gallbladder dyskinesia, other conditions must be excluded:

• Peptic ulcer disease – upper endoscopy.
• Gastroesophageal reflux disease (GERD).
• Irritable bowel syndrome (IBS) – especially with bloating.
• Functional dyspepsia.
• Kidney stones (right side) – urinalysis, CT.
• Musculoskeletal pain (costochondritis, muscle strain).
• Hepatitis or fatty liver.

Treatment – laparoscopic cholecystectomy (if ejection fraction low)

For patients with classic biliary colic, a normal ultrasound, and a low ejection fraction (<35%), laparoscopic cholecystectomy is recommended.

• Success rate: 70‑90% of patients experience significant or complete symptom relief after cholecystectomy.
• Predictors of good outcome: Atypical pain is less likely to respond. Patients with typical post‑prandial pain have the best results.
• Pathology: The removed gallbladder often shows chronic cholecystitis microscopically, even though ultrasound was normal.
• If ejection fraction is borderline (35‑50%): The decision is more nuanced. Some surgeons recommend a trial of medical therapy (dietary changes, antispasmodics) before considering surgery.

Prognosis – symptom relief in 70‑90% after surgery

Long‑term outcomes after cholecystectomy for gallbladder dyskinesia are good for appropriately selected patients. Predictors of success:

• Typical biliary colic (post‑prandial RUQ pain).
• Low ejection fraction (<35%).
• Absence of other functional GI disorders (IBS, dyspepsia).
• Pain reproduced by CCK infusion during HIDA scan (pain with CCK is a positive predictor).

Patients with atypical pain (constant, unrelated to meals) or normal ejection fraction are unlikely to benefit from surgery.

Interactive FAQ – Gallbladder dyskinesia

Disclaimer: This information is for educational purposes. If you have right upper quadrant pain with a normal ultrasound, consult a gastroenterologist at Vivekananda Hospital for a HIDA scan evaluation.