This study was performed to evaluate any predictable factors associated with recurrence of biliary pain in symptomatic gallstone patients who did not undergo cholecystectomy because of operative risk, advanced age, and/or their refusal. The relationships among age, gender, body mass index, frequency of biliary pain before diagnosis, period between the last symptom attack and the hospital visit, size and number of gallstones, gallbladder ejection fraction (GBEF), compliance of ursodeoxycholic acid therapy, and recurrence of biliary pain were examined. The recurrence of biliary pain developed in 15 of 31 patients during the median 29-month follow-up. The cumulative 1-, 2-, and 3-year recurrence rates of biliary pain were 22.8, 40.9, and 53.0% and significantly associated with abnormal GBEF (hazard ratio, 3.12; 95% CI, 1.10-8.87; P = 0.032). In symptomatic gallstone patients with abnormal GBEF, cholecystectomy is strongly advisable because of the high risk of repeated pain attacks.