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Acalculous Biliary Pain

by Ali A. Siddiqui, MD

Acalculous biliary pain is biliary colic without gallstones, resulting from structural or functional disorders; it is sometimes treated with laparoscopic cholecystectomy.

Biliary colic can occur in the absence of gallstones, particularly in young women. Acalculous biliary pain accounts for up to 15% of laparoscopic cholecystectomies. Common causes of such biliary pain include the following:

  • Microscopic stones—not detected by routine abdominal ultrasonography

  • Abnormal gallbladder emptying

  • An overly sensitive biliary tract

  • Sphincter of Oddi dysfunction

  • Hypersensitivity of the adjacent duodenum

  • Possibly gallstones that have spontaneously passed

Some patients eventually develop other functional GI disorders.


  • Unclear

  • Usually ultrasonography and sometimes cholescintigraphy and/or ERCP

The best diagnostic approach remains unclear.

Acalculous biliary pain is suspected in patients with biliary colic when diagnostic imaging cannot detect gallstones. Imaging should include ultrasonography and, where available, endoscopic ultrasonography (for small stones < 1 cm).

Abnormal laboratory tests may reveal evidence of a biliary tract abnormality (eg, elevated alkaline phosphatase, bilirubin, ALT, or AST) or a pancreatic abnormality (eg, elevated lipase) during an episode of acute pain. Cholescintigraphy with cholecystokinin infusion measures gallbladder emptying (ejection fraction); potentially interfering drugs such as Ca channel blockers, opioids, and anticholinergics should not be used. ERCP with biliary manometry detects sphincter of Oddi dysfunction.


  • Unclear but sometimes laparoscopic cholecystectomy

Laparoscopic cholecystectomy improves outcomes for patients with microscopic stones and possibly abnormal gallbladder motility. The role of laparoscopic cholecystectomy or endoscopic sphincterotomy remains problematic. Drug therapies have no proven benefit.

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