Chronic Dyspepsia with a Negative Workup: Consider an Early Cholecystokinin-HIDA Scan

Abstract

Purpose: Dyspeptic symptoms are common in the general population, leading to frequent visits to the doctor and repeated diagnostic tests. Quite often no evidence of structural disease is found that would explain the symptoms. Cholecystokinin-HIDA scan (CCK-HIDA) provides a quantitative method for assessing gallbladder contraction and calculation of the gallbladder ejection fraction (GBEF). We hypothesize that CCK-HIDA would identify a functional gallbladder disorder as the cause of dyspeptic symptoms in a significant percentage of patients with previously negative workup. Methods: We performed a retrospective analysis of patients who underwent CCK-HIDA at our hospital between October 2009 and October 2011. We included patients whose abdominal ultrasound/CT scan, upper and lower GI endoscopy did not provide an explanation for their symptoms. We excluded patients with cholelithiasis/choledocholithiasis, previous sphincterotomy, any biliary surgery, and patients taking prokinetic medications. We collected demographic data, information regarding clinical presentation, abdominal ultrasound and/or CT scan, esogastroduodenoscopy, colonoscopy and CCK-HIDA; we documented GBEF, the presence of reflux into the gallbladder, and duodenogastric reflux. CCK-HIDA was performed according to a standardized protocol, with GBEF of 35% and below being considered abnormal. Data were analyzed using SPSS; parametric methods were employed. Results are shown as median (range). Results: Eighty-six consecutive patients underwent CCK-HIDA in our hospital during the above period; 63 patients (20 M/43 F) met the inclusion criteria; 42 of these patients (13 M/29 F) had evidence of negative GI workup as described above and were included in the analysis. Patients' median age was 52 (range 21-89). Forty-seven percent of patients complained of right upper quadrant pain at presentation; 23% had epigastric pain. Twenty-three out of the 42 patients (55%) had a low GBEF as defined above; median GBEF in this group was 19 (range 3-35). Five patients showed reflux into the gallbladder, or duodenogastric reflux. There was no significant difference between the patients with low and those with normal GBEF in terms of age (p=0.875) or gender (p=0.555). No correlation was found between age and GBEF overall. Conclusion: A significant percentage of patients with dyspeptic symptoms and otherwise negative GI workup exhibit a low GBEF. This is not associated with a particular age or gender. Employment of the CCK-HIDA early in the diagnostic process might help in elucidating faster the etiology of these complaints.