Biliary Hyperkinesia: An Overlooked Cause of Right Upper Quadrant Pain.

Biliary colic, characterized by intermittent right upper quadrant (RUQ) abdominal pain, is a common clinical presentation worldwide. The most frequent underlying causes include acute or chronic cholecystitis and cholelithiasis. In cases where ultrasound findings are unremarkable, patients sometimes undergo a hepatobiliary iminodiacetic acid (HIDA) scan to evaluate gallbladder and biliary tree function. Traditionally, the results are categorized into two outcomes based on the gallbladder ejection fraction (GBEF): biliary dyskinesia or normal function. Biliary dyskinesia, or hypokinesia, is characterized by reduced gallbladder ejection fraction (GBEF), whereas biliary hyperkinesia involves abnormally elevated GBEF, reflecting excessive contractility and remaining poorly understood. We present a case of a 55-year-old female with functional gallbladder disease manifesting as intermittent biliary colic. Initial investigations, including ultrasound and gastroscopy, were unremarkable. However, a HIDA scan revealed an elevated GBEF of 85% at 1 hour, consistent with biliary hyperkinesia. The patient experienced reproducible RUQ pain 40 minutes after consuming a fatty meal. She underwent laparoscopic cholecystectomy, which resulted in complete resolution of her symptoms.  A literature review highlights that many patients with normal imaging findings are diagnosed with biliary dyskinesia based on abnormal GBEF measurements from HIDA scans. While biliary hypokinesia is more commonly recognized, biliary hyperkinesia remains a rare entity. Surgical intervention, particularly laparoscopic cholecystectomy, has been shown to provide significant symptomatic relief in these patients.  In conclusion, many patients with biliary colic remain undiagnosed or are managed medically due to a lack of understanding of the underlying pathophysiology or insufficient diagnostic tools. As demonstrated in this case, we propose that patients with normal baseline investigations for biliary colic should undergo further evaluation, including HIDA scans, to rule out functional gallbladder disorders such as hypokinesia or hyperkinesia. Surgical treatment should be considered as a viable option for symptom relief, particularly in cases where pain causes significant distress and impairs quality of life.