The strict criteria for diagnosis of biliary dyskinesia are 1) RUQ pain associated with transient increases in AlkPhos, AST, ALT, and bilirubin; 2) diameter of common bile duct > 11 mm by ultrasound; 3) delayed emptying of common bile duct (>45 min) after HIDA injection; and 4) elevated basal sphincter of Oddi pressure (by manometry). The first two criteria were clearly not met in this patient at the time the studies were done. The third criteria was actually not met either because, while the amount of radiotracer to be ejected from the gallbladder in 45 minutes was less than normal, the time it took to reach the bowel was normal. The fourth criteria was not measured. A more broad definition of biliary dyskinesia is symptoms and signs of functional biliary obstruction associated with sphincter of Oddi motor abnormalities. This patient may meet this definition, but it is not known since her sphincter of Oddi has not been studied. Once the diagnosis of biliary dyskinesia is established, endoscopic sphincterotomy is the therapy of choice. For this patient, a good course of action would be to first measure basal sphincter of Oddi pressure to confirm the diagnosis of biliary dyskinesia, then perform sphincterotomy if indicated. If the basal sphincter of Oddi pressure is not elevated, there could be another cause for her decreased ejection fraction, such as a mass causing external compression of her pancreaticoduodenal duct. A more likely alternative diagnosis is chronic acalculous cholecystitis. This diagnosis is suggested with symptoms of recurrent biliary colic-like pain, normal ultrasound, normal routine HIDA scan, and decreased ejection fraction. The treatment for chronic acalculous cholecystitis is cholecystectomy.