Does a poorly functioning gallbladder without gallstones always need surgery?

Q. A while back, I had some pain in my upper right abdomen. My doctor ordered some gallbladder tests. I don't have stones, but the test did show there is a blockage; my gallbladder is working at only 4%. The pain does not bother me that much, it is just annoying sometimes. I've been watching my intake of fatty foods and am trying to be healthier. Does this condition always require surgery to remove the gallbladder?

A. Here is how I would approach your situation. First, I would need to know what you mean by blockage. Do you have an actual mechanical blockage in the bile duct? Or is the problem just slow flow out of the bile duct because the gallbladder is not contracting vigorously?

The most common cause of mechanical blockage is a gallstone that gets stuck in the duct. Even though no stones were seen on your tests, there is a remote possibility that a single stone did get lodged in the duct. Scarring causing marked narrowing of the duct or compression from a tumor could also cause mechanical obstruction.

When any mechanical blockage occurs, the duct behind the blockage dilates (enlarges). Since you did not mention this, I assume the duct size is normal.

Mechanical blockages require some type of procedure to open the blockage. And if the gallbladder has become inflamed, then it also should be removed.

What you describe sounds more like a condition known as acalculous biliary pain. Acalculous means "no stones" and biliary pain refers to a specific type of pain in the right side of the upper abdomen. Biliary pain is usually an intermittent, crampy pain that often is brought on by eating, especially fatty foods.

If there is no other explanation for your pain, such as gastritis or acid reflux, then you likely have acalculous biliary pain.

The test used to help diagnose acalculous biliary pain is the gallbladder ejection fraction. The test starts with an intravenous injection of a special dye. The dye is picked up by the gallbladder. The scanner takes pictures and the size of the gallbladder is measured. Then a drug called sincalide may be injected through the same intravenous. This drug causes the gallbladder to contract.

The amount of contraction is calculated by measuring the difference in gallbladder size before and after the injection of CCK. This differential is known as the ejection fraction. Normally it is greater than 35%. I assume that what you meant by "my gallbladder is working at only 4%" is that your ejection fraction is only 4%.

There is debate among experts as to what actually causes the pain associated with a low ejection fraction. Many people with acalculous biliary pain have persistent low-grade inflammation of the lining of the gallbladder. The inflammation may be related to the presence of very tiny stones that are too small to detect on ultrasound or x-rays.

People with a low gallbladder ejection fraction can have symptom relief after gallbladder removal (cholecystectomy). However, if the frequency and severity of pain is lessened by avoiding fatty foods and eating a well-balanced diet, you and your doctor may agree to not rush to the operating room.

Episodes of prolonged severe pain or pain associated with fever or inflammation of the pancreas (pancreatitis) would be indications to proceed with gallbladder surgery.

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