High Gall Bladder Ejection Fraction: Whatʼs Next?

Abstract

Purpose: Cholescintigraphy (HIDA scan) is a commonly used diagnostic tool in almost every hospital in the United States. A diagnosis of acalculous cholecystitis is made when the gall bladder ejection fraction (GBEF) is <35-38%. Studies have shown that low GBEF is sensitive but not a specific indicator of gall bladder inflammation. The higher spectrum of gall bladder ejection fraction has largely remained unnoticed as it is considered normal. However our perspective changed after we encountered this particular case. A 35-year-old woman was seen for chronic abdominal pain of unexplained etiology over the past year. Her past medical history included prolonged course of Clostridium difficile infection which was treated. She also had lupus anticoagulants. The patient reported persistent right upper quadrant discomfort with paroxysms of severe exacerbation which sometimes even woke her from sleep. The pain worsened postprandially. She had constant nausea without vomiting. She also had episodic watery diarrhea about 2 or 3 days out of the week. There was no rectal bleeding. Her weight had been stable. The pain was severe enough to interfere with her daily life and with her work at times. A right upper quadrant sonogram was performed and did not demonstrate any gallstones. Following this an extensive workup was done including upper endoscopy, colonoscopy, capsule endoscopy, small bowel series, CAT scan, and mesenteric angiography. All showed no significant findings. A functional HIDA scan was performed with CCK Administration (0.02 μg/kg over 60 minutes), and her gallbladder ejection fraction was noted to be 94%. This was the only significant finding in her workup. Possible etiologies at this time were endometriosis or gallbladder dysfunction. The patient underwent a planned exploratory laparoscopy and cholecystectomy. The histopathology showed chronic cholecystitis. The patient had partial improvement in symptoms for a short duration; however her symptoms recurred soon after. Treatment options for patients with high gall-bladder EF (>80%) that have unremitting symptoms remains obscure. There are no major studies or guidelines on how to approach patients with hyperdynamic gall bladders. This case illustrates that high EF can be associated with inflammation. It is unfortunate that this particular patient did not get better, but small numbers of studies have shown benefit from surgery. We need an answer to “What's next?” when patients have high gallbladder ejection fractions.