Cholecystectomy for Functional Gallbladder Disorder: A Diagnostic Challenge

Case at a Glance

A 37-year-old Caucasian female presented with a 7-month history of severe nausea, right upper quadrant pain, and chest discomfort. Despite extensive workup showing minimal objective findings, the patient underwent cholecystectomy based primarily on clinical symptoms suggestive of functional gallbladder disorder.

Patient's Story

The patient, a 37-year-old Caucasian female weighing 115 lbs and standing 5'2" tall, presented with a 7-month history of debilitating symptoms including severe nausea, chest pain, right upper quadrant abdominal pain radiating to the right side of her back and neck. Her symptoms were particularly pronounced after eating and included episodes so severe she initially sought emergency care suspecting a myocardial infarction. She reported yellow, loose stools when consuming fatty foods, occasional throbbing pain in the right subcostal region that disrupted sleep, chest spasms, dizziness, and brain fog. Her medical history was notable for thoracic scoliosis since childhood, and she was taking famotidine 40mg for symptom management. She was an occasional social drinker with no tobacco or illicit drug use.

Initial Assessment

The patient initially presented to the emergency department with chest pain concerning for acute coronary syndrome. Cardiac workup including electrocardiogram, echocardiogram, and 2-week Holter monitoring revealed only a single episode of non-sustained ventricular tachycardia, considered benign. Given the persistence and pattern of symptoms, she was referred to gastroenterology for further evaluation of possible hepatobiliary pathology.

The Diagnostic Journey

Comprehensive gastroenterological workup included: (1) Upper endoscopy revealing normal findings except mild lower esophageal inflammation consistent with gastroesophageal reflux; (2) Abdominal ultrasound with no significant abnormalities; (3) HIDA scan showing delayed gallbladder visualization (nearly 2 hours) but normal ejection fraction of 46%; (4) CT abdomen revealing three hepatic hemangiomas and an ovarian cyst, but no acute pathology. The HIDA scan was notable for reproducing the patient's typical nausea during and after the procedure.

Final Diagnosis

Functional gallbladder disorder (biliary dyskinesia) based on clinical presentation and delayed gallbladder visualization on HIDA scan, despite normal ejection fraction.

Treatment Plan

After extensive discussion of risks and benefits, including the uncertain prognosis, laparoscopic cholecystectomy was recommended. The surgeon estimated a 70% probability of symptom improvement based on the clinical presentation and exclusion of other pathology. The decision was made collaboratively with the patient, acknowledging the diagnostic uncertainty but considering the significant impact on quality of life and failure of conservative management.

Outcome and Follow-up

The patient proceeded with laparoscopic cholecystectomy after careful consideration of the risks and benefits. She understood that symptom resolution was not guaranteed but felt the potential for improvement justified the surgical intervention given her significantly impaired quality of life and the comprehensive negative workup for alternative diagnoses.