David J. Bartlett

Background: Hyperkinetic biliary dyskinesia, defined as a gallbladder ejection fraction (EF) ≥80% on cholecystokinin (CCK)-stimulated hepatobiliary iminodiacetic acid scans in the setting of biliary-type pain, has been increasingly recognized as a potential functional gallbladder disorder. The clinical significance of this entity and the role of cholecystectomy remain uncertain. Patients and Methods: We conducted a systematic review and meta-analysis of studies reporting outcomes in patients with CCK-hepatobiliary iminodiacetic acid EF ≥80% who underwent cholecystectomy due to non-acute biliary-type pain. Primary outcomes included mean EF, rates of symptom resolution and improvement following cholecystectomy, and prevalence of chronic cholecystitis on pathology. Secondary outcomes included normal histology rates and symptom reproduction with CCK stimulation. All statistical analyses were conducted in R (version 4.5.0) using a random-effects model to obtain pooled estimates. Results: A total of 14 retrospective studies, including 686 patients, were analyzed. The pooled mean gallbladder EF was 90.27% (95% CI: 88.73–91.80, I ² = 86.6%). Symptom resolution occurred in 83.1% (95% CI: 76.7–89.4, I ² = 76.8%), and symptom improvement in 91.6% (95% CI: 89.0–94.2, I ² = 29.7%) of patients following cholecystectomy. Histopathologic analysis revealed chronic cholecystitis in 85.1% (95% CI: 76.9–93.4, I ² = 90.6%) of surgical specimens, while normal gallbladder histology was rare, observed in only 9.9% (95% CI: 4.6–15.2, I ² = 83.7%). The pooled risk ratio indicated a 6.70-fold higher likelihood of chronic cholecystitis compared with normal histology (95% CI: 3.69–12.17, I ² = 65.2%, P = 0.0022). Functional reproduction of symptoms during CCK stimulation was frequent, with a pooled rate of 78.3% (95% CI: 70.4–86.3, I ² = 35.6%). Egger regression test suggested potential publication bias for the normal histology outcome ( P = 0.0223), but not for symptom resolution ( P = 0.1589). Conclusions: This meta-analysis suggests that a high gallbladder EF in the setting of biliary-type pain could represent clinically relevant hyperkinetic biliary dyskinesia rather than normal physiology. Cholecystectomy appears to provide meaningful symptom relief in appropriately selected patients, and pathologic findings frequently indicate underlying chronic inflammation. Further studies are needed to establish clear diagnostic cutoffs and guide management.

Crohn’s disease is a transmural inflammatory bowel disease, which can progress to stricturing and internal penetrating complications. Computed tomography enterography (CTE) and magnetic resonance enterography (MRE) are utilized with endoscopy to detect and stage small bowel Crohn’s disease. Small bowel strictures and associated penetrating complications are commonly missed complications of fibrostenosing Crohn’s disease at CTE/MRE. This educational review focuses on factors contributing to unreported or overcalled strictures including disease location, postoperative anatomy, erroneous understanding of threshold dilation for stricture diagnosis, and underappreciation for how stricture diagnosis can improve patient care, emphasizing current understanding of Crohn’s small bowel strictures using illustrative cases. In addition, we explain emerging consensus for how strictures and their associated obstruction can be consistently measured and described. We also review frequently missed complications of fibrostenosing Crohn’s disease such as chronic mesenteric venous occlusion and penetrating complications, including blind-ending sinus tracts, and ileoappendiceal and complex enteroenteric fistulas. Finally, common mimics of fibrostenosing Crohn’s disease including NSAID enteropathy, radiation enteritis, and other entities are discussed, highlighting key distinguishing imaging and clinical features. Radiologists must be proactive in identifying strictures to improve patient outcomes and prevent unnecessary delay in surgical intervention or access to targeted biologic therapies.