Biliary Colic, No Stones

I recently saw a 36 year old woman who has a 7 month history of “classic” biliary colic: recurrent post-prandial right upper quadrant pain radiating through to the back, associated with nausea but no vomiting, exacerbated by fatty foods and lasting for one to two hours.

Laboratory and diagnostic studies of Biliary Colic

She has had 2 normal ultrasound exams and a normal HIDA scan with an 88% gallbladder ejection fraction. She has seen two gastroenterologists, undergone a CT scan, ERCP, small bowel series, lactose breath test and colonoscopy, with the only finding being a small ulcer in the sigmoid colon, biopsies of which showed “nonspecific” colitis. She has been treated with proton-pump inhibiters, H2 blockers, tranquilizers, Asacol and Rowesa enemas, all without improvement. Physical exam shows only some mild right upper quadrant tenderness, below the costal margin.

The patient is s/p hysterectomy at age 29 for adenomyosis. Two years ago she developed recurrent pelvic pain and underwent laparoscopic lysis of adhesions and incidental appendectomy with relief of her symptoms. She is otherwise healthy.

Now that the GI guys have run out of ways to finance their BMWs, they have referred her to me for cholecystectomy. Although her symptoms are highly suggestive of biliary colic, I am concerned by the complete lack of any objective data, including a normal GB ejection fraction and the failure of cholecystokinin to reproduce her pain, expecially since most published series in the past few years cite a reduced GB EF as a critereon for elective cholecystectomy in these patients.

How many of you would proceed with laparoscopic cholecystectomy based solely upon her symptoms?

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