Symptomatic Hyperkinetic Gallbladder: An Unrecognized Indication for Cholecystectomy

For decades, low gallbladder ejection fraction (GBEF), measured with hepatobiliary scintigraphy after infusion of sincalide, has been used to diagnose symptomatic biliary hypokinesia and as a predictor of the necessity for cholecystectomy. Recently, gallbladder hypercontractility (GBEF > 79%) has been recognized as a cause of right upper quadrant pain, and cholecystectomy has often resulted in symptom relief. This retrospective study evaluated follow-up data collected after GBEF studies to determine the incidence of cholecystectomy or persistence of symptoms. Methods: We evaluated all GBEF biliary studies performed at our institution between January 1, 2012, and December 31, 2025. Study reports containing "ejection fraction" and "sincalide" were identified to establish the study population. All patients presented with right upper quadrant pain. They received 185 MBq (range, 111-259 MBq) of ^99mTc-mebrofenin intravenously and were imaged in a 20° left anterior oblique position for 60 min. Once the gallbladder was clearly seen, the patients were given a 30-min intravenous infusion of sincalide (0.02 μg/kg), and imaging was continued for a total of 45 min. Patients were categorized as having probable gallbladder disease (cholecystectomy and resolution of symptoms or no cholecystectomy and persistent symptoms) or unlikely gallbladder disease (cholecystectomy and persistent symptoms or no cholecystectomy and resolved symptoms or other diagnosis). Results: In total, 1775 patients were included in the final analysis. Forty percent of patients had a GBEF of greater than 79%, and 27% had a GBEF of less than 39%. Of those who underwent cholecystectomy, 90% of those with a GBEF of less than 39% and 94% of those with a GBEF of greater than 79% experienced symptom relief. The incidence of probable biliary disease was 61% in patients with a low GBEF and 44% in patients with a high GBEF and was lowest in the group with a GBEF of 60%-69% (24% of patients). Conclusion: Our study found that hepatobiliary GBEF is not as accurate as we have assumed. Additional clinical criteria are needed to improve patient selection and positive outcomes. The high percentage of patients with a GBEF exceeding 79% has not been appreciated, as most of the previous studies evaluated healthy subjects and did not examine outcomes. These results should shift how we think about GBEF studies and how the results are reported.