S3583 Beyond the Classic: Atypical Biliary Dyskinesia Successfully Treated With Cholecystectomy

Introduction: Biliary dyskinesia is a functional gallbladder disorder marked by characteristic abdominal pain in the absence of gallstones and supported by unremarkable laboratory markers and a decreased ejection fraction on hepatobiliary iminodiacetic acid (HIDA) scans. Typical abdominal pain, as described by the Rome IV criteria, includes progressively worsening pain that lasts at least 30 minutes, is intermittent and non-positional, disrupts activities of daily living, and is not relieved by acid suppression. Laparoscopic cholecystectomy (LC) has been shown to provide symptomatic relief for the majority of patients with typical symptoms. Data on the benefits for atypical presentations remains scarce. Herein we present a case of atypical biliary dyskinesia with symptom improvement after LC. Case Description/Methods: A 22-year-old woman with no significant past medical history presented to the hospital secondary to several days of constant right upper quadrant abdominal pain, nausea, non-bloody, non-bilious emesis, and anorexia. Vital signs and lab work were unremarkable. Computed tomography abdomen/pelvis was unremarkable. An abdominal ultrasound showed a positive sonographic murphy sign but was negative for cholecystitis. A HIDA scan showed filling of the gallbladder with a decreased ejection fraction. She underwent LC for which the gallbladder was noted to be distended with mild wall thickening. Post-operatively her pain improved. Discussion: Biliary dyskinesia is the most common cause associated with a low ejection fraction on HIDA scans. Despite this, the HIDA scan is considered supportive and not diagnostic due to variations in testing protocols, the fact that healthy patients were used to determine abnormal cutoff values, and by confounding gastrointestinal symptoms that may be triggered by cholecystokinin infusion. There have been several studies that show symptom improvement after LC, including prospective randomized trials. In spite of this, LC for biliary dyskinesia is not universally accepted due to the low overall quality of the data, particularly for atypical presentations. This case supports a potential role for laparoscopic cholecystectomy in patients with atypical biliary presentations. Further studies are warranted to better define its therapeutic value in this subset of patients.