The role of sincalide cholescintigraphy in the evaluation of patients with acalculus gallbladder disease

Predictor of abnormal gallbladder ejection fraction in patients with atypical biliary pain: Histopathological point of view

Cholescintigraphy has traditionally been used as a tool to select patients with biliary pain for elective cholecystectomy. However, atypical biliary pain presents a clinical challenge and there is no literature evaluating the factors of the gallbladder (GB) wall related to abnormal ejection fraction of cholescintigraphy in such patients. Therefore, we aimed to evaluate characteristics of the GB wall in patients with abnormal gallbladder ejection fraction (GBEF) on cholescintigraphy and atypical biliary pain. Patients who underwent cholescintigraphy for atypical biliary pain and subsequent cholecystectomy were initially recruited for this study. Medical records and pathologic findings of these patients were retrospectively reviewed. Parameters that were significant on univariate analysis, including factors of GB wall and cholescintigraphy, were subsequently tested by multivariate analysis to identify independent predictors for abnormal GBEF. Abnormal or low GBEF was defined as GBEF <35%. A total of 41 adult patients were divided into a low GBEF (n = 15) and a high GBEF group (n = 26) based on the cutoff value of 35%. In univariate analysis mean muscle thickness, muscle to total layer ratio, and muscle to fibrosis layer ratio were significantly higher in the low GBEF group than in the high GBEF group. In multivariate analysis, the muscle to fibrosis layer ratio was found to be an independent risk factor for abnormal GBEF (odds ratio = 3.514, 95% confidence interval = 1.058-11.673, P = .04). The fibrosis to total layer ratio was negatively correlated with GBEF in the low GBEF group (r = -0.657, P < .01). Muscle to fibrosis layer ratio was significantly associated with decreased GBEF. The fibrosis thickness ratio also seems to play an important role in patients with decreased GBEF.

Gallbladder dysfunction: how much longer will it be controversial?

BACKGROUND

Motility disorders of the biliary tree [biliary dyskinesia, including both gallbladder dysfunction (GBD), and sphincter of Oddi dysfunction] are difficult to diagnose and to treat.

SUMMARY

There is controversy in the literature in particular regarding the criteria that should be used to select patients for cholecystectomy (CCY) in cases of suspected GBD. The current review covers the history, diagnosis, and treatment of GBD. Key Messages: Only >85% of patients with suspected GBD have relief following CCY, a much lower rate than the nearly 100% success rate following CCY for gallstone disease. Unfortunately, the literature is lacking, and there are no universally agreed-upon criteria for selecting which patients to refer for operation, although cholecystokinin (CCK)-enhanced hepatobiliary iminodiacetic acid scan is often used, with emphasis on an abnormally low gallbladder ejection fraction or pain reproduction at CCK administration. There is a clear need for large, well-designed, more definitive, prospective studies to better identify the indications for and efficacy of CCY in cases of GBD.

Cholecystectomy for biliary dyskinesia: how did we get there?

BACKGROUND

The focus of biliary dyskinesia (BD) shifted within the last 30 years, moving from symptoms after cholecystectomy (CCY) to symptoms with morphological normal gallbladder, but low gallbladder ejection fraction.

METHODS

We searched the pubmed database to systematically review studies focusing on the diagnosis and treatment of gallbladder dysfunction.

RESULTS

Impaired gallbladder contraction can be found in about 20% of healthy controls and an even higher number of patients with various other disorders. Surgery for BD increased after introduction of laparoscopic CCY, with BD now accounting for >20% of CCY in adults and up to 60% in pediatric patients. The majority of cases reported were operated in the USA, which differs from surgical series for cholelithiasis. Postoperative outcomes do not differ between groups with abnormal or normal gallbladder function.

CONCLUSION

Functional gallbladder testing should not be seen as an indicator of relevant biliary tract disease or prognostic marker to identify patients who may benefit from operative intervention. Instead biliary dyskinesia should be considered as a part of a spectrum of functional disorders, which are generally managed conservatively. Small proof of concept studies have demonstrated effects of medical therapy on biliary dysfunction and should thus be never tested in appropriately designed trials.

Diagnostic stringency and healthcare needs in patients with biliary dyskinesia

AIM

We have recently shown an increase in cholecystectomies for biliary dyskinesia. Based on these results, we hypothesized that diagnostic criteria are less stringently applied which may contribute to ongoing resource utilization.

METHODS

Using billing codes, patients seen for biliary dyskinesia were identified and data were extracted from the electronic medical record to confirm the diagnosis, obtain demographic and clinical data and assess resource utilization 1 year prior to and after cholecystectomy.

RESULTS

A total of 972 patients were identified, with 894 undergoing cholecystectomy. In 259 patients, symptoms had started <3 months prior to evaluation. Functional gallbladder imaging revealed a mean gallbladder ejection fraction of 23.1 ± 0.7 %; of the patients undergoing surgery, 116 had a normal gallbladder ejection fraction. Sufficient up data for pre- and post-operative assessment of resource utilization was available for 368 patients. Emergency room (ER) visits decreased from 0.86 ± 0.07 to 0.69 ± 0.03 (P < 0.05), while hospitalization rates remained unchanged after surgery. Patients not meeting consensus criteria for the diagnosis of biliary dyskinesia were more likely to use opioids and have ER visits prior to and after cholecystectomy. Using multiple logistic regression benzodiazepine use, migraine history and prior ER visits independently predicted postoperative resource utilization.

CONCLUSIONS

Our data demonstrate that a significant number of patients undergo cholecystectomy for biliary dyskinesia, even though they do not meet currently accepted diagnostic criteria. While healthcare resource utilization drops within the first year after surgery, ER visits and hospitalizations remain common, suggesting a more limited benefit of surgical approaches in these patients.

The rising tide of cholecystectomy for biliary dyskinesia

BACKGROUND

Expert consensus defines biliary dyskinesia as a rare disorder of the gall-bladder characterised by pain and impaired gall-bladder function.

AIM

To determine trends in cholecystectomy rates for biliary dyskinesia in the United States.

METHODS

As biliary dyskinesia does not have a distinct diagnosis code, the narrative diagnoses for patients were reviewed and abstracted for 200 patients treated for the most commonly used diagnosis codes for biliary dyskinesia (validation sample). Time trends in cholecystectomies and hospitalisations for biliary diseases were assessed using the Nationwide Inpatient Sample (Agency for Healthcare Research and Quality) based on codes for cholecystectomy and diagnosis codes for different biliary disorders.

RESULTS

In the validation sample, biliary dyskinesia accounted for 81% of the patients with ICD-9 code 575.8 (gall-bladder disease not elsewhere specified). Between 1997 and 2010, admissions for acute cholecystitis and complications of gallstone disease decreased slightly, whereas admissions with the primary diagnosis code ICD-9 575.8 tripled. This rise was most pronounced in the paediatric population (700% increase), with biliary dyskinesia accounting for more than 10% of cholecystectomies. Compared with acute biliary diseases, significantly more of the elective hospitalisations were covered by private insurances.

CONCLUSIONS

Practice patterns differ from expert opinion, with biliary dyskinesia accounting for an increasing fraction of cholecystectomies. The rise in these elective interventions is associated with a shift to a younger, low risk and predominantly privately insured population. Considering the benign nature of biliary dyskinesia, it is time to reassess the need for operative interventions, which have never been compared with active conservative therapy.

Sincalide cholescintigraphy--32 years later: evidence-based data on its clinical utility and infusion methodology

Sincalide cholescintigraphy was first reported to have clinical utility in 1980. Since then, many publications have found that a reduced gallbladder ejection fraction (GBEF) can confirm the clinical diagnosis of acalculous chronic gallbladder disease and predict symptomatic relief with cholecystectomy. However, some publications had not found the test clinically predictive. Many different sincalide infusion methods and normal values have been used. It had been suspected that the different infusion methods and normal values might account for the variability in reported utility. Furthermore, clinical review articles have raised questions about the evidence-based quality of the published data on the diagnostic utility of sincalide cholescintigraphy. A recently published multicenter trial has established the optimal methodology for sincalide infusion and normal values. A subsequent multispecialty consensus publication has recommended that this method be the standard method for sincalide infusion, specifically, a 60-minute infusion of 0.02 μg/kg (abnormal GBEF, <38%). The consensus publication also recommended that a large, multicenter, randomized, prospective trial was needed to confirm the utility of a low GBEF to predict acalculous chronic gallbladder disease and the patient's response to cholecystectomy.

The cholecystokin provocation HIDA test: recreation of symptoms is superior to ejection fraction in predicting medium-term outcomes

BACKGROUND

The (99m) technetium labelled hepato imino diacetic acid (HIDA) scan is widely used in the investigation of patients with typical biliary pain but whose trans-abdominal ultrasound scan (US) is normal. Although the standard measure by which the HIDA scan is deemed positive is the presence of an ejection fraction (EF) of <35% following provocation with cholecystokinin (CCK), there still remains debate as to the usefulness of this measure. The aim of this study was to compare the roles of EF and symptom provocation following CCK infusion in relation to the outcome following laparoscopic cholecystectomy (LC). More specifically, we aimed to review the resolution of symptoms for our significant population of patients with normal HIDA scan EFs for whom surgery has traditionally been deemed inappropriate.

PATIENTS AND METHODS

All patients undergoing LC for a presumed diagnosis of biliary dyskinesia were identified from a prospectively maintained database. Data were collected regarding pre-operative symptoms, EF and symptom provocation during the CCK HIDA scan, histological findings, early symptomatic outcome, and medium-term follow-up.

RESULTS

During the period from March 2006 to October 2009, 42 patients with biliary symptoms but a negative US were referred for assessment by a single surgeon. There were 31 women and 11 men with a mean age of 39.0 ± 12.6 years. All underwent a CCK HIDA scan of which 17 were positive with an EF <35% and the remaining 25 were negative. All patients reported recreation of symptoms following administration of CCK. All gallbladders were delivered intact for histological assessment and all but one showed evidence of chronic cholecystitis. At each postoperative visit, approximately 2 weeks following the procedure, all patients reported resolution of symptoms. After a mean of 18.7 ± 12.1 months symptom recurrence had been noted in only one of 42 (2.4%).

CONCLUSIONS

The CCK HIDA scan is a useful study in the investigation of acalcalous cholecystitis; however, we would suggest that recreation of symptoms following CCK provocation is superior to EF for the identification of underlying chronic cholecystitis. Indeed, a normal gallbladder ejection fraction does not necessarily rule out a biliary aetiology of symptoms for this patient population.

Comparison of sonography and scintigraphy in the evaluation of gallbladder functional studies with cholecystokinin

OBJECTIVE

Both sonography and scintigraphy have been used to evaluate gallbladder function with the use of sincalide (cholecystokinin [CCK]). However, the reported ejection fractions (EFs) for the two modalities are not the same. The techniques measure slightly different parameters. This study directly compared both techniques performed simultaneously on the same participants.

METHODS

Twenty healthy volunteers were evaluated with sonography and scintigraphy to estimate the gallbladder EF simultaneously. The gallbladder EF was calculated at 5-minute intervals for 1 hour.

RESULTS

The mean EFs +/- SD were 66.3% +/- 20% and 49% +/- 29% for sonography and scintigraphy, respectively. The mean times to the peak EF were 38 +/- 12 and 33 +/- 9 minutes for sonography and scintigraphy. An average time of 34 minutes was noted after radiopharmaceutical injection before CCK administration for the scintigraphic studies. The earliest time to the peak EF for sonography was 15 minutes, and the latest time to the peak EF was 60 minutes (mode, 40 minutes); for scintigraphy, the earliest and latest times were 15 and 50 minutes (mode, 30 minutes), respectively. One participant could not be evaluated secondary to nonfilling of the gallbladder on scintigraphy. There was wider variability of the gall-bladder EF with scintigraphy than sonography.

CONCLUSIONS

Scintigraphy estimated a lower EF than sonography, had wider EF variability than sonography, and required additional time (>30 minutes more) to complete the study. Scintigraphy could not be performed in 5% of the participants because of nonfilling of the gallbladder. The use of sonography to estimate the gallbladder EF is less time-consuming and less costly. With these techniques, the range of normal gallbladder EFs should be adjusted for the technique used.

Laparoscopic Cholecystectomy for Biliary Dyskinesia in Children: Report of 100 Cases from a Single Institution

Laparoscopic cholecystectomy (LC) is increasingly performed in the pediatric population. Biliary dyskinesia (BD) is largely responsible for this increase and is presently the most common indication for LC in this age group. In our institution the diagnosis of BD is made in patients with biliary symptoms, absence of biliary stones, and an ejection fraction <35 per cent on hydroxy iminoadiacetic acid (HIDA) scan. We reviewed our experience of 100 children with BD that underwent LC. Data that was prospectively collected and entered into electronic medical records by gastroenterologists, primary care physicians, and pediatric surgeons was reviewed and analyzed. Patients were symptomatic for an average of 15 months before undergoing surgery. Seventy-seven per cent reported resolution of symptoms from 6 months to 5 years following LC, whereas the rest complained of persistent symptomatology. When the two groups were compared, patients with persistent symptoms were more likely to be female and to have longer symptom duration. An ejection fraction <35 per cent reliably predicts successful outcome of LC in patients with BD. The diagnosis of BD should be entertained early in the differential of functional abdominal pain in children and referred to Pediatric Surgery when its presence is confirmed.

HIDA scan ejection fraction does not predict sphincter of Oddi hypertension or clinical outcome in patients with suspected chronic acalculous cholecystitis

BACKGROUND

Hepatobiliary iminodiacetic scan with ejection fraction (HIDA EF) is used to evaluate chronic acalculous cholecystitis (CAC). A presumed etiology of CAC is sphincter of Oddi hypertension (SOH). In this study, we evaluated the value of HIDA EF to predict patient response to laparoscopic cholecystectomy and to identify SOH.

METHODS

A prospective study of 93 patients with biliary pain but without gallstones (CAC) who underwent preoperative HIDA EF was conducted. At laparoscopic cholecystectomy, transcystic antegrade biliary manometry was performed to determine the SO pressure. Patients were evaluated postoperatively for response to cholecystectomy. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. The outcomes were compared with the clinical impression.

RESULTS

Of the 93 patients with both HIDA EF and SOP measurements, 50 had abnormal EF (< 35%); of these, 29 had SOH (SO pressure > or = 40 mmHg). Of the 43 patients with normal HIDA EF, 30 had SOH. The sensitivity was 49%, specificity 38%, PPV 58%, and NPV 30%. Eighty-six of the 93 patients returned for follow-up evaluation. Follow-up ranged from 0 to 99 months, with a mean of 26.4 months. Overall, 73 patients (85%) improved. Of the 46 with abnormal HIDA EF, 42 (91%) improved. Of the 40 patients with normal HIDA EF, 31 (77.5%) improved. The sensitivity was 57.7%, specificity 69.2%, PPV 91.3%, and NPV 22.5%.

CONCLUSION

Although the PPV of abnormal HIDA EF is high, it is not much better than the clinical impression. The sensitivity and specificity are marginal. The NPV is poor. Based on the review of these 93 patients, HIDA EF is not reliable for identifying CAC. We recommend that patients with normal HIDA EF have additional testing or consultation before ruling out CAC. HIDA EF does not predict SOH.

Functional hepatobiliary disease: chronic acalculous gallbladder and chronic acalculous biliary disease

Chronic acalculous gallbladder and chronic acalculous biliary disease are considered functional hepatobiliary diseases. Cholescintigraphy provides physiologic imaging of biliary drainage, making it ideally suited for their noninvasive diagnosis. For chronic acalculous gallbladder disease, calculation of a gallbladder ejection fraction during sincalide cholescintigraphy can confirm the clinical diagnosis and has become a common routine procedure in many nuclear medicine clinics. Published data generally confirm a high overall accuracy for predicting relief of symptoms with cholecystectomy. However, data also exist suggesting it is not useful. The discrepant results probably are caused by the various different methodologies that have been used for sincalide infusion. Proper methodology of sincalide infusion is critical for providing accurate reproducible results, minimizing false positive studies, and preventing adverse side effects. The most common causes for the postcholecystectomy pain syndrome are partial biliary obstruction secondary to stones or tumor and sphincter of Oddi dysfunction. The latter is a partial biliary obstruction at the level of the sphincter. This has long been considered a functional hepatobiliary disease because of the lack of anatomical abnormalities. Sphincterotomy is the present treatment; however, diagnosis requires invasive procedures, such as endoscopic retrograde cholangiopancreatography and sphincter of Oddi manometry, which has a high complication rate and is not widely available. The unique ability of cholescintigraphy to image biliary drainage allows noninvasive diagnosis. Different methodologies have been reported, many with good overall accuracy. Various pharmacologic interventions and quantitative methodologies have been used in conjunction with cholescintigraphy to enhance its diagnostic capability. Further investigations are needed determine the optimal methodology; however, cholescintigraphic methods have already a clinical role in the diagnosis of sphincter of Oddi dysfunction and will be used increasingly in the future.

Controversies concerning pathophysiology and management of acalculous biliary-type abdominal pain

Acalculous biliary-type abdominal pain is a commonly encountered clinical problem whose pathophysiology is unclear and evaluation and management are controversial. Cholecystokinin cholescintigraphy to measure the gallbladder ejection fraction (GEF) has been advocated as a criterion for cholecystectomy. However, there is no consensus regarding the dose and rate of infusion of cholecystokinin, both of which can alter the GEF, and the definition of an abnormal ejection fraction varies among studies. Many but not all studies have concluded that a low GEF predicts good outcomes after cholecystectomy, but most studies suffer from poor methodology and there is only one prospective randomized controlled trial. Also, some patients with a normal GEF have responded to cholecystectomy. Another controversial area has been the role of sphincter of Oddi dysfunction (SOD) in patients with biliary-type pain and gallbladder in situ. Some reports suggest an overlap between SOD and low GEF, although a causal relationship has not been established. Yet another subject of interest is the role of visceral hyperalgesia in patients with acalculous biliary-type pain. We have reviewed the relevant literature relating to these issues and have highlighted the controversial aspects. In the absence of high-quality studies, an evidence-based treatment algorithm is difficult to design but will be proposed. More prospective controlled trials are warranted to better define the appropriate evaluation and management of patients with this syndrome.

Acalculous biliary tract disorders: the value of fatty meal-cholescintigraphy

BACKGROUND

The management of patients with symptoms consistent with biliary tract disease but without evidence of cholelithiasis is difficult. This study was undertaken to test the value of cholescintigraphy in predicting the success of cholecystectomy in patients with acalculous biliary tract disorders.

MATERIAL AND METHODS

A prospective study was carried out on 73 patients presenting with recurrent upper quadrant pain without documented evidence of gallstones on ultrasound. Fatty meal-cholescintigraphy was performed on all patients and the gallbladder ejection fraction was calculated. Laparoscopic cholecystectomy was performed in patients with ejection fractions of <40%, followed by histopathological analysis and assessment of symptomatic improvement.

RESULTS

There were 43 men and 30 women with a mean age of 33.4 years. Forty-one patients had abnormal ejection fractions. All except one patient had a laparoscopic cholecystectomy. The pathological diagnosis of chronic cholecystitis was made in 33 patients and acute on chronic cholecystitis documented in four patients. Five patients had cholesterolosis and two of these had associated chronic cholecystitis. All except three patients had complete relief of symptoms post-operatively with a mean follow-up of 10 months.

CONCLUSION

Modified cholescintigraphy is a useful test for predicting which patients with acalculous biliary tract disease benefit from a cholecystectomy.

Does gallbladder ejection fraction predict outcome after cholecystectomy for suspected chronic acalculous gallbladder dysfunction? A systematic review

The clinical utility of cholecystokinin-cholescintigraphy with calculation of a gallbladder ejection fraction (GBEF) in patients with suspected chronic acalculous gallbladder dysfunction (CAGD) remains controversial. It was our aim to critically evaluate the literature on the utility of the GBEF to predict outcome of patients with suspected CAGD. We performed an electronic search of the MEDLINE database for articles published between 1980 and 2002 and a manual search of references from bibliographies of identified articles. Only articles in English that concerned adults were screened. Data extracted included both qualitative and quantitative data reported on the study groups, cholescintigraphic technique, interventions, treatment outcomes, and trial methodologic characteristics. Twenty-three publications met the inclusion criteria. All were considered of poor methodologic quality. All but three studies were retrospective case series, only one was randomized, and none were adequately blinded, used adequate controls, or enrolled a sufficient number of patients. Five studies used a cut-off value for an abnormal GBEF that was different than the value used by the others, one study did not provide a cut-off value, and several did not report details of the cholescintigraphic technique (namely, the rate of cholecystokinin infusion). Studies varied in their outcome measures and the criteria for success. The overall assessment of outcome in 19 studies concluded that calculation of a GBEF was useful in patients with suspected CAGD. The low methodologic quality of the studies precluded a meta-analysis approach to the data. Use of a calculated GBEF to diagnose and predict treatment outcome in suspected CAGD has not been adequately studied. Although most studies report utility of GBEF in predicting symptom outcome after cholecystectomy in patients with suspected CAGD, quality evidence is lacking, thereby precluding a definitive recommendation regarding its use. More high quality trials are needed.

Stimulation with fatty meal (Lipomul) to assess gallbladder emptying in children with chronic acalculous cholecystitis

OBJECTIVE

Chronic acalculous cholecystitis previously has been diagnosed by hepatobiliary scan stimulated with intravenous octapeptide of cholecystokinin. This compound may soon be unavailable in the United States. The goal of this study was to describe the characteristics of children with chronic acalculous cholecystitis diagnosed by hepatobiliary scintigraphy with oral Lipomul challenge, and to evaluate their clinical response to cholecystectomy.

METHODS

Retrospective chart review of patients with no gall stones detected by abdominal ultrasound or computed tomography with gallbladder ejection fraction (GBEF) <35% after Lipomul challenge who subsequently underwent cholecystectomy. Fifteen patients with a mean age of 14.9 +/- 0.9 years were included. The mean duration of symptoms before evaluation was 8.2 +/- 2.5 months.

RESULTS

The mean GBEF after Lipomul challenge was 16.7% +/- 2.7%. All patients had abdominal pain. Ninety percent had right upper quadrant pain and 86% had typical biliary colic. Pain was precipitated by fatty meals in 73.3%. Histopathologic analysis of the gallbladder demonstrated chronic cholecystitis in 80% of cases. The mean postoperative follow-up was 20 +/- 5 months. Six months after the surgery, nine patients (60%) were asymptomatic, five (33%) had marked improvement of symptoms, and one (6%) was unchanged. At the time of latest follow-up, symptoms had reappeared in two patients who had been asymptomatic at the 6-month visit (13%). Seven patients (46%) remained asymptomatic, five (33%) had marked improvement but continued to have some persistent symptoms, and one (6%) was unchanged.

CONCLUSIONS

Chronic acalculous cholecystitis may be responsible for right upper quadrant pain in children without gallstones. A GBEF <35% at 30 minutes after Lipomul challenge may be useful in identifying patients who could benefit from cholecystectomy. Lipomul may be a good alternative to cholecystokinin for gallbladder stimulation during scintigraphy.

Systematic review and meta-analysis: does gall-bladder ejection fraction on cholecystokinin cholescintigraphy predict outcome after cholecystectomy in suspected functional biliary pain?

BACKGROUND

Patients with suspected functional biliary pain often undergo cholecystectomy if a decreased gall-bladder ejection fraction (GBEF <35%) is demonstrated by cholecystokinin cholescintigraphy. However, the validity of GBEF in predicting which patients will have symptomatic relief following cholecystectomy is unclear.

AIM

To determine whether patients with suspected functional biliary pain with decreased GBEF have a better symptomatic outcome after cholecystectomy than those with normal GBEF.

METHODS

Systematic review and meta-analysis of the published literature through MEDLINE and EMBASE databases.

RESULTS

We included nine studies with a total of 974 patients with suspected functional biliary pain; 362 patients underwent cholecystectomy. Most studies assessed outcome by direct patient interview. Mean ages across the studies ranged from 35 to 47 years; 78% of all patients were female. Mean duration of follow-up after surgery ranged from 1 to 2.5 years. After cholecystectomy, 94% of the patients with reduced GBEF had a positive outcome compared to 85% among those with normal GBEF. The pooled Mantel-Haenszel odds ratio for positive outcome was 1.37 (95% confidence interval 0.56-3.34), P=0.56.

CONCLUSION

These data do not support the use of GBEF to select patients with suspected functional biliary pain for cholecystectomy. Prospective randomized trials are required if this practice is to be evidence-based.

Value of measuring gallbladder motility in clinical practice

Measurement of gallbladder motility is a powerful research tool, but its value in clinical practice is uncertain. Three main conditions have been investigated for potential clinical application of this measurement. The first potential application is for identification of patients at risk of recurrence following gallstone dissolution with medical therapy. Results in this clinical setting are disappointing due to the low positive predictive value for gallstone recurrence in sluggish gallbladder emptying. The second potential application is for identification of obese patients at risk of gallstone formation during rapid weight loss. In this condition, a high negative predictive value has been reported for a normal gallbladder emptying pattern. The third potential application is for patients with recurrent biliary colic and acalcolous gallbladder disease. The diagnostic value of a provocative test involving intravenous cholecystokinin injection as a method of identifying patients likely to benefit from cholecystectomy is uncertain, partly as a consequence of non-standardized methodology. The balance of evidence reported in this review suggests a low inherent value of measurement of gallbladder motility in clinical practice. Acalcolous gallbladder disease is the clinical setting deserving further investigation on the value of the cholecystokinin provocative test, but this test needs to be standardized.

Chronic Acalculous Biliary Disease: Cholecystokinin Cholescintigraphy is Useful in Formulating Treatment Strategy and Predicting Success after Cholecystectomy

Patients with symptoms consistent with biliary colic who do not demonstrate calculi on routine sonography present a diagnostic dilemma for clinicians. For those patients in whom other disease entities have been excluded and in whom the history and physical examination exemplify classic signs and symptoms of biliary disease we show in this study that cholecystokinin cholescintigraphy with calculation of gallbladder ejection fraction is a predictor of pathology as well as subsequent symptom relief after cholecystectomy. The spectrum of pathology that makes up chronic acalculous biliary disease lacks a distinct definition, yet this review shows that cholecystokinin cholescintigraphy offers the surgeon the means to better counsel his or her patient with regard to surgical indications, options, and benefits. We reviewed 26 patients who had no gallstones detectable, had gallbladder ejection fraction <35 per cent, and were status postlaparoscopic cholecystectomy for suspected chronic acalculous biliary disease. Our results show histopathologic evidence of chronic cholecystitis in 100 per cent, and 92 per cent of the patients had improvement of symptoms and satisfaction with the operation to the point that they would undergo the surgery again without reservation.

Normal values for sincalide cholescintigraphy: comparison of two methods

PURPOSE

To establish normal gallbladder ejection fraction (GBEF) values for two sincalide (cholecystokinin [CCK]) infusion dose rates, 0.01 microg per kilogram of body weight infused for 3 minutes and 0.01 microg/kg infused for 60 minutes.

MATERIALS AND METHODS

Twenty healthy subjects were examined. GBEFs were calculated for the 3-minute infusion and for each 15-minute interval for the 60-minute infusion. Normal values were determined by using the mean +/- 2 SDs and a more rigorous statistical analysis.

RESULTS

With the 3-minute infusion, GBEFs were significantly more variable than with the 45- and 60-minute values for the 60-minute infusion (P < .01, .002). With intervals including 95% of the population, the GBEF lower normal range was 16.8% for the 3-minute infusion but 31% and 41% for the 45- and 60-minute values, respectively. GBEFs of less than 35% were noted in six (30%) of 20 healthy subjects with the 3-minute infusion but in only one with the 60-minute infusion. Hepatobiliary ultrasonography was performed in six of seven subjects with GBEF of 36% or less, and US findings in all six were normal.

CONCLUSION

A 3-minute infusion of sincalide, 0.01 microg/kg, produces too variable a GBEF response to establish a clinically useful normal range. With 0.01 microg/kg infused for 60 minutes, clinically useful normal values were established at 45 and 60 minutes.

Cholecystokinin cholescintigraphy: clinical indications and proper methodology

Cholecystokinin is a useful diagnostic adjunct to cholescintigraphy. Clinical indications include contracting the gallbladder before cholescintigraphy in patients fasting greater than 24 hours, during cholescintigraphy to diagnose sphincter of Oddi dysfunction, and after cholescintigraphy to exclude acute acalculous cholecystitis, differentiate common duct obstruction from normal variation, and to confirm the diagnosis of chronic acalculous cholecystitis. Proper methodology is mandatory for a diagnostically useful test. Data presented shows that a 3-minute infusion of 0.01 or 0.02 microg/kg is nonphysiologic and often results in ineffective contraction similar to that seen with a bolus infusion. Normal gallbladder ejection (GBEF) values cannot be established using a 3-minute infusion because of the wide variability in response. Instead, infusions of 30 or 60 minutes are required. Normal GBEF values have been established for these methods and are 30% and 40%, respectively.

Diagnostic accuracy of 99Tcm-HIDA with cholecystokinin and gallbladder ejection fraction in acalculous gallbladder disease

The diagnostic accuracy and clinical impact of 99Tcm hepatic iminodiacetic acid (HIDA) imaging with cholecystokinin (CCK) was investigated in a prospective study of 359 patients over an 11 year period. All patients presented with right upper quadrant biliary type pain and had a normal ultrasound investigation prior to imaging. CCK was administered as a 3 min infusion at peak gallbladder uptake of HIDA. A gallbladder ejection fraction (GBEF) was used to quantify the gallbladder response to CCK. Two hundred and forty-four of 359 (68%) patients had an abnormal GBEF (< or = 35%). One hundred and thirty-four of 141 (95%) patients who underwent cholecystectomy had abnormal surgical/histological findings and/or relief of symptoms on long-term (mean 5.7 years) follow-up. Clinical follow-up, mean of 5.9 years, of the patients with GBEF > 35% showed 73/79 (92%) of them with little evidence of gallbladder disease. For a total 261 patients with mean clinical follow-up of 5.7 years the sensitivity of GBEF measurement is 95%, specificity is 92% and overall accuracy is 94%. It is concluded that 99Tcm-HIDA imaging, with a 3 min infusion of CCK, is a highly accurate technique and valuable in the diagnostic management of patients with suspected acalculous gallbladder disease.

An audit of biliary scintigraphy in a district general hospital (1993-1998) with special reference to the investigation of acalculous gallbladder disease

One hundred and ninety nine cholescintigrams were performed at our hospital between January 1993 and December 1998. Of these, 96 were performed as part of the investigation of right upper quadrant or epigastric pain in patients whose prior biliary ultrasound scans had shown no abnormalities. In this group of patients, 60 cholescintigrams were reported as normal, 28 as abnormal and eight as equivocal. A review of the case notes for this group was made, with 91 out of 96 case notes being retrieved. Thirteen of the 58 (22%) patients with normal cholescintigrams either underwent or had been offered cholecystectomy, compared with 22 of the 27 (81%) with 'definitely abnormal' cholescintigrams. Of the subset of patients with abnormal cholescintigrams subsequently undergoing cholecystectomy, 16 out of 18 were found to have histologically abnormal gallbladders, while 11 out of 18 reportedly had their symptoms cured or improved. A fatty meal is used in our unit as the stimulus to gallbladder contraction, in contrast to the majority of papers published in the literature. We believe that the use of a fatty meal is acceptable and that the use of intravenous exogenous cholecystokinin is probably best reserved for the small group of patients with equivocal scintigrams who may require further investigation.

Gallbladder ejection fraction: correlation of scintigraphic and ultrasonographic techniques

PURPOSE

The assessment of gallbladder function and ejection fraction using sincalide-enhanced biliary scintigraphy is a useful way to evaluate patients with recurrent right upper quadrant pain but no gallstones.

MATERIALS AND METHODS

We wanted to determine whether gallbladder contraction measured by ultrasonography could be used in place of biliary scintigraphy. Biliary scans with an infusion of sincalide and concurrent ultrasonography were performed in 17 patients with histories of recurrent abdominal pain and no evidence of gallstones by ultrasound.

RESULTS

Gallbladder ejection fractions calculated by ultrasound and scintigraphy using standard techniques showed only a weak correlation. The poor performance of ultrasound appears to arise because the variable shape of the gallbladder invalidates the calculation of its volume by the formula for a prolate spheroid. When gallbladders that were ellipsoidal were subselected, correlation was improved. The level of training of the sonologist did not have a significant effect on the results.

CONCLUSION

Gallbladder ejection fraction calculated by ultrasonography cannot be used routinely as a substitute for biliary scintigraphy.

Cholecystectomy is an effective treatment for biliary dyskinesia

BACKGROUND

An increasing number of reports indicate symptomatic relief of biliary colic symptoms after cholecystectomy for biliary dyskinesia. Despite this, cholecystectomy as a treatment for biliary dyskinesia remains controversial. Our aim was to determine efficacy of cholecystectomy in alleviating biliary dyskinesia symptoms and the correlation with histologic findings.

METHODS

Records of patients with gallbladder ejection fraction <35% between January 1994 and February 1999 were reviewed. Gallbladder pathology and degree of symptomatic improvement were determined on follow-up.

RESULTS

Of the 27 cholecystectomy patients, 24 (89%) had significant improvement, 2 (7%) had partial improvement, and 1 (4%) had minimal improvement. Ten patients (43%) had normal gall-bladder, and 9 (90%) of them had significant improvement after cholecystectomy. Of the 6 nonsurgical patients, none had significant improvement, 4 (67%) had partial improvement, and 2 (33%) had minimal improvement.

CONCLUSIONS

Biliary dyskinesia patients who underwent cholecystectomy had significantly greater symptom improvement compared with nonsurgical patients. Pathologic correlation suggests chronic inflammation may not be the only cause of gallbladder dysfunction. Cholecystectomy should be a first-line therapy for biliary dyskinesia patients.

Cholecystectomy for suspected biliary dyskinesia in children with chronic abdominal pain

BACKGROUND/PURPOSE

The authors reviewed their experience with a group of children with chronic abdominal pain, delayed gallbladder emptying, and no cholelithiasis. Clinical presentation, diagnostic evaluation, and effect of cholecystectomy on symptoms were investigated.

METHODS

Twenty-nine children were suspected of having biliary dyskinesia. Diagnosis was based on symptoms of upper abdominal pain in conjunction with a lack of sonographically apparent gallstones, a cholecystikinin (CCK)-stimulated gallbladder ejection fraction of less that 40% at 30 minutes, and a lack of any other clear cause for symptoms. All patients underwent cholecystectomy.

RESULTS

The duration of symptoms before operation was between 3 weeks and 4 years. All patients were evaluated by abdominal ultrasonography and CCK cholescintigraphy. Symptoms were relieved completely in 23 (79%) of the patients who underwent cholecystectomy. Five children had persistent pain after cholecystectomy and one had nausea.

CONCLUSIONS

Symptoms suggestive of biliary colic in children without evidence for cholelithiasis frequently may represent biliary dyskinesia. CCK cholescintigraphy should be pursued in these patients. Relief of symptoms after cholecystectomy should be expected in a majority of those with an ejection fraction of less that 40%.

Laparoscopy and acalculous cholecystitis

Acalculous cholecystitis is probably more common than the medical literature would suggest. This paper reviews a series of 13 patients who presented with symptoms of cholecystitis and who had normal ultrasound or cholecystogram examinations. Eleven patients underwent cholecystectomy and all had their symptoms ameliorated or cured. Laparoscopy is suggested as an early diagnostic procedure in these patients, followed by cholecystectomy if there is objective laparoscopic evidence of cholecystitis.

Cholecystokinin (CCK)-HIDA scintigraphy in patients with suspected gall-bladder dysfunction

Cholecystokinin hepatobiliary (CCK-HIDA) scintigraphy is used to triage patients with chronic abdominal pain and suspected gall-bladder dysfunction. This study evaluates the predictive value of CCK-HIDA for clinical outcome after surgical and medical therapy. Fifty-six patients (45 females), mean age 43 +/- 9 years, with otherwise normal investigations, including normal ultrasound, fasted for more than 8h and then had 70MBq technetium-99m-EHIDA injected. One and a half hours later 15 ng/kg CCK was infused over 45 min. Seventy minutes dynamic imaging commenced 5 min prior to infusion. An abnormal gall-bladder ejection fraction (GBEF) was defined as < 50%. Patients were treated medically, or by cholecystectomy, depending on the surgeon's overall assessment, including results of the CCK-HIDA study. Patient status was then obtained in 51/56 patients at least 3 months after the scan or at least 1 month after surgery. All surgical specimens were reviewed independently for pathological changes of chronic acalculous cholecystitis. Of the 11 patients with an abnormal gall-bladder ejection fraction, nine (82%) underwent cholecystectomy, all of whom achieved total symptomatic cure, while two patients underwent other therapy, both of whom remained symptomatically unchanged. Of the 40 patients whose gall-bladder ejection fraction was normal, only five (12.5%) underwent cholecystectomy, of whom four were cured and one partially improved at follow up. Of the 35 patients with a normal gall-bladder ejection fraction and who underwent forms of therapy other than cholecystectomy, nine were cured symptomatically, 13 improved, 10 remained unchanged and three were symptomatically worse at follow up.(ABSTRACT TRUNCATED AT 250 WORDS)

Cholesterolosis in patients with chronic acalculous biliary pain

The outcome of patients with cholesterolosis was compared with that of those with chronic cholecystitis operated on for chronic acalculous biliary pain. A total of 55 patients with acalculous biliary pain with a median symptom duration of 24 (range 6-120) months were investigated by dynamic cholescintigraphy and followed for a median of 24 (range 12-60) months. Thirty-five patients underwent cholecystectomy, of whom 22 had a low gallbladder ejection fraction (under 35 per cent), with symptomatic improvement in 21 of these (P < 0.01). All four patients with a normal ejection fraction (35-50 per cent) improved after cholecystectomy but only four of nine with a high ejection fraction (over 50 per cent) did so. Results of histological examination were available in 32 patients and revealed cholesterolosis in 20. A low ejection fraction was found in 16 patients with cholesterolosis, of whom 15 showed symptomatic improvement after cholecystectomy; the other four patients had a high fraction and all improved after cholecystectomy. Overall, symptoms in 19 of 20 patients with cholesterolosis improved after cholecystectomy compared with only seven of 12 with chronic cholecystitis (P = 0.03).

Acalculous biliary pain: cholecystectomy alleviates symptoms in patients with abnormal cholescintigraphy

A 45-minute infusion of an octapeptide of cholecystokinin (Kinevac; Squibb Diagnostics, New Brunswick, NJ) was used to measure the gallbladder ejection fraction during cholescintigraphy in 40 normal volunteers. Cholecystokinin cholescintigraphy was shown to be a reproducible test. The maximum mean gallbladder ejection fraction occurred 15 minutes after cholecystokinin infusion and was 74.5% +/- 1.9% (mean +/- SEM). A gallbladder ejection fraction greater than 40% (mean -3SD) was arbitrarily defined to be normal. The gallbladder ejection fraction test was then used to identify patients with acalculous biliary symptoms who may respond to cholecystectomy. A total of 103 patients was tested; 21 had abnormal gallbladder ejection fractions and were randomized into two groups, cholecystectomy or no operation. These patients were followed up symptomatically at 3-month intervals for 13-54 months (mean, 34 months). Of the 11 patients who underwent cholecystectomy, 10 (91%) lost their symptoms and 1 improved. Of the 10 patients in the group that did not undergo surgery, all continued to be symptomatic, 2 of whom requested cholecystectomy after 13 and 24 months, respectively. Of the 13 gallbladders obtained from surgery, 12 showed evidence of chronic cholecystitis, muscle hypertrophy, and/or narrowed cystic duct. A normal gallbladder ejection fraction was recorded in 82 patients, and further treatment was left to the discretion of their referring clinician. On follow-up, 50 patients were asymptomatic and 10 were symptomatic without specific treatment of the biliary tract; 14 underwent cholecystectomy, 8 of whom were asymptomatic. Pathological abnormalities were recorded in 6 of the removed gallbladders. It is concluded that the gallbladder ejection fraction obtained after a 45-minute infusion of cholecystokinin during cholescintigraphy is a reproducible measure of gallbladder emptying, and that cholecystectomy alleviates the biliary-type pain of patients with a reduced gallbladder ejection fraction.

Augmented cholescintigraphy: its role in detecting acute and chronic disorders of the hepatobiliary tree

Cholecystagogue cholescintigraphy can be employed as a means of (1) confirming the surgeon's and/or gastroenterologist's clinical impression of symptomatic chronic acalculous biliary disease, (2) better understanding the pathophysiology of gallbladder disease, (3) preparing patients for hepatobiliary scintigraphy who have fasted for longer than 24-48 hours and who are suspected of acute cholecystitis, and (4) reducing the time required to confirm the clinical impression of acute cholecystitis. Morphine-augmented cholescintigraphy is also used to decrease the time required to determine cystic duct patency. Phenobarbital-augmented cholescintigraphy is used as a means of increasing the accuracy of hepatobiliary scintigraphy in differentiating neonatal hepatitis from biliary atresia. Nonpharmacological interventions and augmentations have been employed to maintain the high degree of accuracy of cholescintigraphy in confirming the clinical impression of acute cholecystitis. The efficacy of these modalities in detecting acute and chronic disorders of the hepatobiliary tree as well as how and why they are performed comprise the contents of this article.