I HAVE A PATIENT WITH BILIARY-TYPE PAIN, BUT NO OTHER EVIDENCE OF BILE DUCT DISEASE (NORMAL DIAMETER DUCT ON ULTRASOUND, NORMAL LIVER FUNCTION TESTS). HOW SHOULD SUCH A PATIENT BE MANAGED?

Right upper quadrant (RUQ) pain syndrome is most common in women, particularly those who are young to middle-aged. The first question we should ask is whether the gallbladder is intact. Our first efforts should be to thoroughly investigate whether there is any evidence of gallbladder disease. Computed tomography is generally performed to look for structural abnormalities, but it is generally negative. A high-quality RUQ ultrasound should be done. If there is any evidence of gallbladder sludge or stone disease, it is reasonable to offer laparoscopic cholecystectomy. If negative, then a cholecystokinin (CCK)-stimulated hydroxyindole diaminoacetic acid (HIDA) nuclear medicine scan can be performed to look for a diminished ejection fraction, indicative of “gallbladder dyskinesia.” If abnormal, then cholecystectomy can be recommended. Although I also recommend this approach, I counsel patients that there is an approximately 50% chance or less of clinical improvement, and very limited supporting data. If the CCK HIDA scan is negative, I recommend endoscopic ultrasound, which may find subtle evidence of gallbladder sludge, chronic pancreatitis, ductal abnormalities, or occasionally some other surpriser-I once found pericardial effusions suggestive of pericarditis that were not suspected by any other test. In very rare circumstances, I will recommend consideration of empirical cholecystectomy in the absence of any gallbladder disease, even by all of the previously mentioned tests. I do not recommend endoscopic retrograde cholangiopancreatography (ERCP) or sphincter of Oddi manometry (SOM) for unexplained RUQ pain in patients with intact gallbladders.