Actually, cholecystectomy in the absence of gallstones is becoming quite a
bit more common than in the past. The diagnosis of biliary dyskinesia is
seen with increasing frequency. That diagnosis is made by HIDA scan with
volumetric gallbladder emptying in response to IV administration of CCK. An
ejection fraction of less than 30% is considered a positive test, as well as
duplication or exacerbation of the pain with the injection. Personally, I
like to also see some supporting factors, such as strong family history or
classic pain presentation (fatty food->RUQ pain->radiate to back...etc).

A typical workup might be ultrasound of the GB. If negative, then probably
an EGD for ulcer or esophagitis. If negative then perhaps empiric trial of a
PPI, or maybe ambulatory pH testing and esophageal manometry *or*  HIDA/CCK
. . Maybe a gastroenterology consult in there somewhere for irritable bowel
syndrome workup.

There is an entity called hypertensive Sphincter of Oddi. This can be
painful, and can cause RUQ pain that can be troublesome. The diagnosis is
made by manometry of the sphincter and common duct and treatment is
sphincterotomy. There's only one place in this state that has that equipment
(Mayo Clinic doesn't have it), and the gastroenterologist that runs the
program won't even do the testing unless the patient continues to have that
pain after cholecystectomy. I've actually seen a few patients with this -
one of those situations where the diagnosis is elusive, and this GI
consultant recommended empiric cholecystectomy. Interestingly, it eliminates
the problem in most of the situations I've done this, even in the absence of
in the absence of ANY of the usual indications. The 2 patients whom it
didn't help turned out to have hypertensive sphincter of Oddi and
sphincterotomy fixed it.

So much of what I learned in my residency has turned out to be wrong....

HMc