Further diagnostic studies of the eight patients in the nonoperative group and the three patients in the operative group who did not improve have failed to identify a source for their symptoms. Discussion Patients with symptoms of biliary tract disease but no evidence of gallstones or other etiologic source pose a diagnostic and therapeutic dilemma. Most often these patients have undergone repeated examinations of their biliary and upper gastrointestinal tracts with no demonstrable disease. Most of these patients are felt to have acalculous biliary tract disease. In the past, several diagnostic tests have been used to investigate this possibility.
Some authors advocate inspection of duodenal aspirates for the presence of cholesterol crystals.
They have shown a correlation between crystal formation and low GBEFs. The HIDA scan has long provided reliable diagnosis of acute acalculous cholecystitis when nonvisualization of the gallbladder is associated with prompt visualization of the extrahepatic bile ducts and the duodenum. The recent development of CCK analogs and its use in combination with HIDA scans allows for the evaluation of the gallbladder contractility and ejection fractions. In the present study we reviewed the patient's initial symptoms, the GBEFs, their response to CCK stimulation, and the follow-up symptoms at 11 months after laparoscopic cholecystectomy or after 11 months of medical management. This study confirms previous reports that patients who have undergone HIDA scans and are found to have GBEF less than 35 per cent can be treated with cholecystectomy with relief of symptoms.