For five years, my patient has been experiencing several episodes a year of what appears to be biliary colic — severe epigastric and right-upper-quadrant abdominal pain that begins shortly after eating, is associated with nausea and vomiting and lasts about four hours.
Two abdominal ultrasounds were normal, as were a complete blood count, liver function tests, and lipase and amylase levels. An upper GI series was negative. The gastroenterologist ordered a cholecystokinin-hepato-iminodiacetic acid (CCK-HIDA) scan. The biliary ejection fraction was 3%, and the patient experienced nausea after injection of the CCK.
Both the gastroenterologist and a surgeon have recommended cholecystectomy. Please explain the CCK-HIDA scan. Would you advise surgery for this patient? — Daniel Federman, MD, Newtown, Conn.
When a patient has chronic acalculous gallbladder dysfunction (CAGD), a traditional HIDA scan may be inconclusive, since no stones are present to lead to frank cystic duct obstruction. In these cases, use of CCK, a powerful stimulant for gallbladder contraction, can be helpful.
In the CCK-HIDA scan, or “gallbladder ejection fraction test,” gallbladder function is determined by measurement of the percent decrease in gallbladder radioactivity over a specified period after infusion of CCK. Normal gallbladder ejection fractions range from 35%-75%, and numerous studies have suggested that for patients with values <35%, cholecystectomy can be highly effective for symptom relief. Therefore, I understand why the gastroenterologist and surgeon have recommended cholecystectomy.
However, a study has brought the utility of this test into question (Am J Gastroenterol. 2003;98:2605-2611), and I would advise you to read this excellent review before making a final decision. — Daniel G. Tobin, MD (156-4)