By Dr. Richard Nguyen, DO, FACS, FACOS | Board-Certified Surgeon | San Jose & Los Gatos, CA
Right-sided upper abdominal pain after meals, nausea, and bloating are classic gallbladder complaints, so it can be confusing when an ultrasound comes back "normal" and no gallstones are found. If that sounds familiar, you may be dealing with biliary dyskinesia, also called functional gallbladder disorder. For San Jose and Los Gatos patients with symptoms but no stones, the question is usually whether a gallbladder removal (cholecystectomy) could help, and how a HIDA scan fits into that decision. Here is how I explain it in the office.
Your gallbladder stores bile made by the liver and squeezes it into the small intestine when you eat, especially fatty foods. In biliary dyskinesia the gallbladder does not empty properly even though there are no stones in it. The result can feel very similar to a gallstone attack: pain that builds after eating, often under the right rib cage or in the upper middle abdomen, sometimes spreading to the back or right shoulder blade.
These symptoms overlap with many other conditions, including acid reflux, ulcers, gastritis, irritable bowel syndrome, and liver or pancreas problems. That is why a careful workup matters before anyone discusses surgery.
The first step is usually blood work (liver enzymes, lipase) and an abdominal ultrasound to look for gallstones, sludge, or gallbladder wall changes. Depending on your symptoms, an upper endoscopy may be recommended to check for reflux disease or an ulcer. Gallstone disease is far more common than dyskinesia, so stones are looked for first. If you already know you have stones, see our guide on signs you may need your gallbladder removed.
A HIDA (hepatobiliary iminodiacetic acid) scan is a nuclear medicine test. A small amount of radioactive tracer is given through an IV, travels to the liver, and is excreted into the bile. Images follow the tracer into the gallbladder. A medication called cholecystokinin (CCK) is then given to make the gallbladder contract, and the scan calculates the gallbladder ejection fraction, which is the percentage of bile the gallbladder pushes out.
Many specialists consider an ejection fraction below roughly 35 to 40 percent to be low, although cutoffs vary between facilities. Just as important is whether the CCK injection reproduces your usual pain during the test. A low number alone does not make the diagnosis, and a borderline number does not rule it out. The result has to be read together with your story and exam.
Treatment for biliary dyskinesia is not as clear-cut as treatment for gallstones, and I think patients deserve to hear that plainly. Surgery is generally considered when all of the following apply:
Studies of gallbladder removal for biliary dyskinesia report symptom improvement in many carefully selected patients, particularly those with a low ejection fraction and classic pain. The evidence is weaker than for gallstone disease, and some patients keep some symptoms afterward. Individual results vary, which is why selection and a shared decision matter so much.
Gallbladder removal is typically performed with minimally invasive laparoscopic surgery through a few small incisions, and many patients go home the same day. Most people return to desk work within about a week, with lifting limits for a short period afterward. For a closer look at the expected timeline and eating plan, read our gallbladder surgery recovery and diet guide. Like any operation, it carries risks, including bleeding, infection, bile duct injury (uncommon), and digestive changes such as looser stools in some people, which we review before surgery.
Because the symptoms are shared with so many conditions, I would rather take extra time to confirm the cause than operate quickly and miss the real problem. Reflux, a hiatal hernia, or stomach inflammation can all mimic gallbladder pain, and removing a healthy-looking gallbladder will not fix them.
These can signal gallstone complications, such as an infected gallbladder, a blocked bile duct, or pancreatitis, and they need prompt evaluation.
Yes. Biliary dyskinesia, gallbladder inflammation without stones (acalculous cholecystitis), and tiny stones or sludge that ultrasound can miss can all cause gallbladder-type symptoms. A full evaluation helps sort these out.
You receive an IV and lie still for about one to two hours. The tracer dose is small. Some people feel cramping or nausea when CCK is given, which can actually be helpful if it matches your usual pain. Tell your care team about any allergies or pregnancy beforehand.
Not definitely. Outcomes are best when symptoms are classic and the HIDA scan is clearly abnormal. Because other conditions can mimic gallbladder pain, careful testing first improves the odds of a good result. Individual results vary.
Yes. Bile still reaches your intestine directly from the liver. Some people notice looser stools or fat intolerance at first, and these often settle over time.
Dr. Richard Nguyen, DO, FACS, FACOS, is a board-certified general and bariatric surgeon serving San Jose and Los Gatos, California. Fellowship-trained in minimally invasive and bariatric surgery at Vanderbilt University, he has performed more than 15,000 procedures and is nationally recognized for non-mesh and advanced hernia repair. At Lifetime Surgical he combines advanced surgical technique with personalized, patient-centered care.
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