[size=20px]A 12-year-old is referred to your clinic by their pediatrician for evaluation of crampy, post-prandial right upper quadrant pain of 8 months duration. A right upper quadrant ultrasound showed no gallstones or evidence of chronic cholecystitis. A HIDA scan was obtained and demonstrated an ejection fraction of 25%. The report notes that the patient had pain with CCK injection. What is the most appropriate next step in management?

 

a Offer cholecystectomy or medical management based upon patient preference

 

b Medical management

 

c Cholecystectomy

 

d Refer to a gastroenterologist for further evaluation[/size]

C

C

C

C

C

C

Correct answer

d Refer to a gastroenterologist for further evaluation

 

This patient has typical biliary pain, no gallstones, and a gallbladder ejection fraction less than 35%, all of which suggest she is an appropriate candidate for observation or cholecystectomy. Lifestyle changes and medical management (diet modification, multimodal pain control, trial of H2 blockers) lead to symptom resolution in up to 75% of patients. Short symptom duration (less than 12-13 months) is associated with improvement after cholecystectomy, although prospective studies are lacking to confirm the direction and causality in the association. There is no clear evidence that either is superior in this setting. Patients with suspected biliary dyskinesia should also be evaluated by a gastroenterologist to rule out other causes of abdominal pain, especially functional dyspepsia, before cholecystectomy is offered.