Lisa Jung, ND, FABNG
Abstract
Biliary hyperkinesia is an emerging functional gallbladder disorder characterized by elevated gallbladder ejection fraction and right upper quadrant pain in the absence of gallstones. This case study follows a 32-year-old woman with chronic nausea, fatigue, and postprandial abdominal pain whose workup revealed persistently elevated ejection fractions on HIDA scans. A comprehensive naturopathic protocol—including dietary modification, hepatobiliary support, and digestive enzymes—significantly improved symptoms. Persistent discomfort ultimately led to a laparoscopic cholecystectomy, resulting in complete symptom resolution. This case emphasizes the importance of considering biliary hyperkinesia in chronic RUQ pain and demonstrates how integrative, patient-centered care optimizes both pre- and post-surgical outcomes.
Introduction
Right upper quadrant abdominal pain without gallstones presents a diagnostic challenge for clinicians. While biliary dyskinesia with low gallbladder ejection fraction is well recognized and common, biliary hyperkinesia has only recently gained clinical attention, with some providers deeming it controversial. Causes of biliary hyperkinesia are unknown and considered commonly idiopathic, though there are some contributing factors. These factors include cholecystitis, medications that affect gallbladder motility, cholecystokinin (CCK) dysfunction, and obesity.4 Emerging data from the Mayo Clinic suggest a diagnostic threshold of GBEF ≥81% correlates strongly with symptomatic improvement following cholecystectomy.5 This case illustrates an integrative approach combining naturopathic care and conventional intervention in a patient with persistent RUQ pain due to biliary hyperkinesia.
Case Presentation
A 32-year-old female presented with a four-year history of chronic nausea, fatigue, brain fog, constipation, and intermittent RUQ abdominal pain worsened after fatty meals. RUQ pain has been so severe that it has negatively impacted her quality of life. She could no longer work or drive herself due to the pain and brain fog, which impacted her executive function and decision-making. Her medications included ondansetron 4mg prn and acetaminophen 500mg prn for nausea and pain, respectively. Extensive gastrointestinal evaluation included two colonoscopies and one EGD — all unremarkable. Abdominal ultrasound was also demonstrated to be unremarkable, with no presence of gallstones or ductal dilation. Two HIDA scans revealed elevated GBEF of 91% and 62%, 2 years apart, raising suspicion for biliary hyperkinesia. Following the first HIDA scan, the patient worked with a nutritionist, leading to a decrease in EF to 62%. Previous laboratory findings with PCP were all unremarkable, with the exception of low ferritin, omega fatty acids, and vitamin B12 levels.
Differential Diagnosis
The patient’s prolonged symptoms warranted an extensive differential diagnosis for RUQ abdominal pain and nausea. Cholecystitis, cholelithiasis, peptic ulcer disease, pancreatitis, celiac disease, sphincter of Oddi dysfunction, and irritable bowel syndrome were excluded through normal laboratory markers, negative serologies, unremarkable endoscopy and other imaging, and stable pancreatic enzymes. The persistently elevated GBEF on two HIDA scans supported the diagnosis of biliary hyperkinesia.
Interventions
Naturopathic management focused on optimizing digestive function, addressing the hepatobiliary pathways, and reducing biliary spasms. Interventions included an anti-inflammatory, low-fat diet, hepatobiliary support, digestive enzymes with ox bile, and others (refer to the table below). Multivitamin and iron supplements were also in the plan to correct deficiencies seen in the laboratory findings.
Outcome
Patient was on a comprehensive treatment plan as outlined for 6 months, reporting significant improvement on the pain scale from 9-10/10 to a 3/10. Despite significant symptom relief with the naturopathic intervention, the patient continued to experience RUQ discomfort when attempting to increase dietary fat intake. This persistent discomfort led to a shared decision for a laparoscopic cholecystectomy. Within weeks of the procedure, the patient reported significant improvement in nausea and abdominal pain (1-2/10). Energy levels increased, cognitive clarity improved, and bowel regularity normalized. At a three-month follow-up, the patient demonstrated sustained symptomatic relief and overall enhanced quality of life, with consistent post-cholecystectomy diet and digestive enzymes with ox bile.
Naturopathic Protocols
| Intervention | Dosage/Instruction | Purpose |
| Anti-inflammatory, low-fat diet | Focus on whole foods & high fiber.Smaller, more frequent meals are also helpful | Reduce oxidative stress that impairs gallbladder motility/function19Reduce CCK-mediated gallbladder hyper-contraction18 |
| Fumitory (Fumaria officinalis) tincture | 1mL tincture TID with meals | Gallbladder affinity herb; acts as a cholagogue and spasmolytic17 also mild laxative effect that can additionally address constipation17 |
| Curcumin phytosome extract | 1-2 gram QD | Reduce biliary inflammation and support hepatic detoxification 15, 16 |
| Tauroursodeoxycholic acid (TUDCA) | 250mg TID with meals | Enhance bile excretion and improve fat digestion11 |
| Digestive enzymes with ox bile | 1-2 capsules TID with meals | Support lipid metabolism and digestive aid, with a small dose of ox bile to help with GI motility and constipation20 |
| Reduced Glutathione | 250-500mg once daily, without food if tolerable | Major antioxidant support for Entero-hepatic-biliary support21 |
| Probiotics | Lactobacillus spp. + Bifidobacterium spp., with a 2-month course of Saccharomyces boulardii | Address gut microbiome balance and regulate enterohepatic signaling12 |
| Mucosal support formula | e.g., aloe vera, slippery elm, L-glutamine, zinc carnosine1 scoop mixed into water/tea TID with meals | Address mucosal integrity damage from excessive & rapid bile flow with hyper-contraction 13, 14 |
Discussion
Biliary hyperkinesia is increasingly recognized as a functional gallbladder disorder. Data from the Mayo Clinic indicate that patients with GBEF ≥81% are more likely to experience pain resolution following cholecystectomy. Comprehensive naturopathic care offers valuable strategies that can aid in symptom relief by modulating inflammation, improving bile physiology, and gallbladder contraction. Surgical intervention may possibly be avoided with such a plan; however, the treatment should always incorporate shared decision-making between the provider and patient, analyzing the risks versus benefits and impact on the patient’s quality of life.
Conclusion
This case underscores the clinical importance of considering biliary hyperkinesia in patients presenting with chronic RUQ pain and elevated GBEF. A comprehensive diagnostic approach, shared decision-making, and integrative strategies can improve symptom resolution and long-term gallbladder and overall digestive health.
Lisa Jung, ND, FABNG, is a licensed naturopathic doctor with a special focus on gastrointestinal health. She is also a fellow of the American Board of Naturopathic Gastroenterology (FABNG). After graduating from Bastyr University, Kenmore, Dr. Jung has completed 3 years of accredited naturopathic residency, including a chief residency at Susan Samueli Integrative Health Institute at the University of California, Irvine. After residency, she started her telemedicine practice, Jung Naturopathic Wellness, based in California. Through her practice, Dr. Jung helps individuals address their chronic digestive issues through an integrative approach. For more information, visit www.drlisajung.com, or TikTok & Instagram: @dr.lisajung.
References
1. Kartik V, et al. Optimal hepatobiliary scintigraphy gallbladder ejection fraction cutoff to predict chronic cholecystitis. Mayo Clinic. 2023. PMID: 37366537.
2. Abu Hijleh A, et al. Outcomes of laparoscopic cholecystectomy for biliary hyperkinesia: A multicenter review. J Am Coll Surg. 2024.
3. Sadek M, et al. Hyperkinetic biliary dyskinesia and surgical outcomes: Case series and literature review. J Am Coll Surg. 2023.
4. Samuel I. “The Chronic Acalculous Symptomatic Hyperkinetic (CASPER) Gallbladder.” JSM Gastroenterol Hepatol. 2023.
5. Black J, Fann C. Biliary hyperkinesia in adults: Case report and literature review. ACS Case Rev Surg. 2023.
6. American Gastroenterological Association. Rome IV Diagnostic Criteria for Functional Gallbladder Disorders. Gastroenterology. 2016.
7. Sharp KW, et al. Systematic review and meta-analysis of cholecystectomy for biliary hyperkinesia. Surg Endosc. 2022.
8. Mayo Clinic Guidelines. Functional gallbladder disorders and surgical management. Mayo Clinic Proceedings. 2023.
9. American College of Gastroenterology. ACG clinical guideline: Evaluation of biliary dyskinesia. Am J Gastroenterol. 2023.
10. Transl Gastroenterol Hepatol. Functional gallbladder disorders in adults and children. 2024.
11. Kusaczuk M. Tauroursodeoxycholate-Bile Acid with Chaperoning Activity: Molecular and Cellular Effects and Therapeutic Perspectives. Cells. 2019.
12. Fogelson KA, Dorrestein PC, Zarrinpar A, Knight R. The Gut Microbial Bile Acid Modulation and Its Relevance to Digestive Health and Diseases. Gastroenterology. 2023.
13. Hewlings S, Kalman D. A Review of Zinc-L-Carnosine and Its Positive Effects on Oral Mucositis, Taste Disorders, and Gastrointestinal Disorders. Nutrients. 2020.
14. Rao R, Samak G. Role of Glutamine in Protection of Intestinal Epithelial Tight Junctions. J Epithel Biol Pharmacol. 2012.
15. Hu RW, Carey EJ, Lindor KD, Tabibian JH. Curcumin in Hepatobiliary Disease: Pharmacotherapeutic Properties and Emerging Potential Clinical Applications. Ann Hepatol. 2017.
16. Kumar H, Dhalaria R, Kimta N, et al. Curcumin: A Potential Detoxifier Against Chemical and Natural Toxicants. Phytother Res. 2025.
17. Yarnell E. Natural Approach to Gastroenterology. 2nd ed. Vol II. Healing Mountain Publishing Inc; 2010:439.
18. Froehlich F, Gonvers JJ, Fried M. Role of nutrient fat and cholecystokinin in regulation of gallbladder emptying in man. Dig Dis Sci. 1995.
19. Zhu H, Jin L, Zhang Z, et al. Oxidative balance scores and gallstone disease: mediating effects of oxidative stress. Nutr J. 2025.
20. Hellström PM, Nilsson I, Svenberg T. Role of bile in regulation of gut motility. J Intern Med. 1995.
21. Vairetti M, Di Pasqua LG, Cagna M, Richelmi P, Ferrigno A, Berardo C. Changes in Glutathione Content in Liver Diseases: An Update. Antioxidants (Basel). 2021.