Hepatobiliary scanning standards fail to identify symptomatic patients with chronic acalculous cholecystitis

Matthew D. Stanley, Tiffany N. Wright, Daniel L. Davenport, J. Scott Roth, Andrew C. Beranrd


Background: Patients with chronic biliary colic-like pain and normal transabdominal ultrasonography (TUS) typically undergo nuclear hepatobiliary imaging (HIDA) with cholecystokinin (CCK) injection and gall bladder ejection fraction (EF) calculation to identify gallbladder dyskinesia. Most literature suggests EF£35% indicates biliary

dyskinesia.  We hypothesize that presence of chronic biliary colic-like symptoms predicts favorable outcome after cholecystectomy (CCY) in patients with normal hepatobiliary imaging.

Methods: A retrospective review of 1295 patients who underwent laparoscopic CCY from January 2006 to December 2010 in a tertiary care institution was completed. Patients with gallstones on TUS or diagnostically abnormal HIDA scans were excluded. Symptom reproduction upon CCK injection was not considered for inclusion criteria but was noted upon chart review. Patient outcome, favorable or unfavorable, was determined from postoperative follow-up.

Results:  One hundred and six patients (8.19%) with normal TUS and HIDA scans were included in the final analysis. Ninety-six patients (90.6%) reported a favorable outcome (i.e., significant improvement or complete resolution of their symptoms) on follow-up. Ninety-three patients with favorable outcomes and six patients with unfavorable outcomes presented with an initial complaint of right upper quadrant (RUQ) and/or epigastric pain (p=0.001, sensitivity=95.9%, PPV=93.9%). Sixty-eight patients with favorable outcomes and one patient with an unfavorable outcome presented with an initial complaint of postprandial RUQ and/or epigastric pain (p<0.001, specificity=90.0%, PPV=98.6%).

Conclusion:  Hepatobiliary imaging fails to identify all patients suffering from chronic acalculous cholecystitis.  Presence of chronic biliary colic-like symptoms predicts benefit from CCY.


Hepatobiliary; cholecystitis; gall bladder

Full Text:


Adams DB, Tarnasky PR, Hawes RH, et al. Outcome after laparoscopic cholecystectomy for chronic acalculous cholecystitis. Am Surg 1998;64:1-5; discussion 5-6. http://www.ncbi.nlm.nih.gov/pubmed/?term=Adams+D%2C+Hawes+RH+Am+Surg

Barbara L, Sama C, Morselli Labate AM, et al. A population study on the prevalence of gallstone disease: the Sirmione Study. Hepatology 1987;7:913-7. http://www.ncbi.nlm.nih.gov/pubmed/3653855

Barron LG, Rubio PA. Importance of accurate preoperative diagnosis and role of advanced laparoscopic cholecystectomy in relieving chronic acalculous cholecystitis. J Laparoendosc Surg 1995;5:357-61. http://www.ncbi.nlm.nih.gov/pubmed/?term=Barron+LG%2C+Rubio+PA

Chen PF, Nimeri A, Pham QH, et al. The clinical diagnosis of chronic acalculous cholecystitis. Surgery 2001;130:578-81, discussion 581-3. http://www.sciencedirect.com/science/article/pii/S0039606001956867

Davis GB, Berk RN, Scheible FW, et al. Cholecystokinin cholecystography, sonography, and scintigraphy: detection of chronic acalculous cholecystitis. AJR Am J Roentgenol 1982;139:1117-21. http://www.ajronline.org/doi/abs/10.2214/ajr.139.6.1117

Fink-Bennett D, DeRidder P, Kolozsi W, et al. Cholecystokinin cholescintigraphic findings in the cystic duct syndrome. J Nucl Med 1985;26:1123-8. http://jnm.snmjournals.org/content/26/10/1123.long

Fink-Bennett D, DeRidder P, Kolozsi WZ, et al. Cholecystokinin cholescintigraphy: detection of abnormal gallbladder motor function in patients with chronic acalculous gallbladder disease. J Nucl Med 1991;32:1695-9. http://jnm.snmjournals.org/content/32/9/1695.long

Fuller RA, Kuhn JA, Fisher TL, et al. Laparoscopic cholecystectomy for acalculous gallbladder disease. Proc (Bayl Univ Med Cent) 2000;13:331-3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1312225/

Gracie WA, Ransohoff DF. The natural history of silent gallstones: the innocent gallstone is not a myth. N Engl J Med 1982;307:798-800. http://www.nejm.org/doi/full/10.1056/NEJM198209233071305

Johanning JM, Gruenberg JC. The changing face of cholecystectomy. Am Surg 1998;64:643-7, discussion 647-8. http://www.ncbi.nlm.nih.gov/pubmed/9655275

Krishnamurthy GT, Bobba VR, Kingston E. Radionuclide ejection fraction: a technique for quantitative analysis of motor function of the human gallbladder. Gastroenterology 1981;80:482-90. http://www.ncbi.nlm.nih.gov/pubmed/7450441

Majeski J. Gallbladder ejection fraction: an accurate evaluation of symptomatic acalculous gallbladder disease. Int Surg 2003;88:95-9. http://www.ncbi.nlm.nih.gov/pubmed/12872903

Middleton GW, Williams JH. Diagnostic accuracy of 99Tcm-HIDA with cholecystokinin and gallbladder ejection fraction in acalculous gallbladder disease. Nucl Med Commun 2001;22:657-61. http://www.ncbi.nlm.nih.gov/pubmed/11403177

Misra DC Jr, Blossom GB, Fink-Bennett D, et al. Results of surgical therapy for biliary dyskinesia. Arch Surg 1991;126:957-60. http://archsurg.jamanetwork.com/article.aspx?articleid=595139

Morris-Stiff G, Falk G, Kraynak L, et al. The cholecystokin provocation HIDA test: recreation of symptoms is superior to ejection fraction in predicting medium-term outcomes. J Gastrointest Surg 2011;15:345-9. http://link.springer.com/article/10.1007%2Fs11605-010-1342-4

Pickleman J, Peiss RL, Henkin R, et al. The role of sincalide cholescintigraphy in the evaluation of patients with acalculus gallbladder disease. Arch Surg 1985;120:693-7. http://archsurg.jamanetwork.com/article.aspx?articleid=591054

Poynter MT, Saba AK, Evans RA. Chronic acalculous biliary disease: cholecystokinin cholescintigraphy is useful in formulating treatment strategy and predicting success after cholecystectomy. Am Surg 2002;68:382-4. http://www.ncbi.nlm.nih.gov/pubmed/?term=Poynter+MT%2C+Saba+AK%2C+Evans+RA

Ross M, Brown M, McLaughlin K, et al. Emergency physician-performed ultrasound to diagnose cholelithiasis: a systematic review. Acad Emerg Med 2011;18:227-35.


Topper TE, Ryerson TW, Nora PF. Quantitative gallbladder imaging following cholecystokinin. J Nucl Med 1980;21:694-6. http://jnm.snmjournals.org/content/21/7/694.long

Yap L, Wycherley AG, Morphett AD, et al. Acalculous biliary pain: cholecystectomy alleviates symptoms in patients with abnormal cholescintigraphy. Gastroenterology 1991;101:785-93. http://www.ncbi.nlm.nih.gov/pubmed/?term=Yap+L%2C+Wycherley+AG%2C+Morphett+AD

Yost F, Margenthaler J, Presti M, et al. Cholecystectomy is an effective treatment for biliary dyskinesia. Am J Surg 1999;178:462-5. http://www.sciencedirect.com/science/article/pii/S0002961099002287

Zech ER, Simmons LB, Kendrick RR, et al. Cholecystokinin enhanced hepatobiliary scanning with ejection fraction calculation as an indicator of disease of the gallbladder. Surg Gynecol Obstet 1991;172:21-4. http://www.ncbi.nlm.nih.gov/pubmed/?term=Zech+ER%2C+Simmons+LB%2CKendrick+RR

Ziessman HA. Functional hepatobiliary disease: chronic acalculous gallbladder and chronic acalculous biliary disease. Semin Nucl Med 2006;36:119-32. http://www.sciencedirect.com/science/article/pii/S000129980500070X

DOI: http://dx.doi.org/10.18103/mra.v0i3.71


  • There are currently no refbacks.