Effect of endoscopic sphincterotomy on gallbladder motility

Long-term effects of endoscopic papillary balloon dilation on gallbladder motility

We prospectively studied long-term (5 years) effects of endoscopic papillary balloon dilation (EPBD) on gallbladder motility. Thirteen patients with intact gallbladders (six with and seven without gallbladder stones) who had undergone EPBD for choledocholithiasis were enrolled in this study. Gallbladder volumes, while fasting and after dried egg yolk ingestion, were determined by ultrasonography, before and at 7 days, 1 month, and 1, 2, and 5 years after EPBD. Before EPBD, the gallbladder had a larger fasting volume and lower yolk-stimulated maximum contraction than in normal controls. Seven days after EPBD, fasting volume was decreased and maximum contraction was increased, regardless of whether the patient had gallbladder stones, showing significant differences from the pre-EPBD values. At 1 month to 5 years after EPBD, these changes were far less evident and gallbladder function did not differ significantly from baseline. EPBD does not adversely affect gallbladder motility in the long-term (5 years).

Approach to idiopathic recurrent pancreatitis

Acute pancreatitis is caused by acute or chronic alcohol intake or choledocholithiasis in approximately 80% of cases. In the absence of alcohol abuse or gallstones, a variety of established and putative factors must be considered, any of which can cause a single or recurrent attacks of acute pancreatitis. When the underlying cause eludes detection following an initial thorough search and leads to a second attack, the term idiopathic acute recurrent pancreatitis (IARP) is applied. This article discusses IARP and its work-up.

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Medium-term effects of endoscopic papillary balloon dilation on gallbladder motility

BACKGROUND

Endoscopic papillary balloon dilation (EPBD) for removal of bile duct stones tends to preserve papillary function. However, EPBD may exert beneficial or deleterious effects on gallbladder motility. This was a prospective, medium-term investigation (2 years) of the effects of EPBD on gallbladder motility.

METHODS

Twelve patients with intact gallbladders (6 with and 6 without gallbladder stones) who underwent EPBD for choledocholithiasis were enrolled in this study. Gallbladder motility was examined before EPBD and at 7 days, 1 month, 1 year, and 2 years after EPBD. Gallbladder volumes, measured after fasting and after ingestion of dried egg yolk, were determined by US.

RESULTS

All patients were asymptomatic during the 2-year follow-up period. Before EPBD, particularly in patients with cholelithiasis, the gallbladder had a larger fasting volume and lower yolk-stimulated maximum contraction compared with normal control subjects. Seven days after EPBD, fasting volume was decreased and maximum contraction was increased, both significantly compared with pre-EPBD values and regardless of the presence or absence of gallbladder stones. At 1 month, 1 year, and 2 years after EPBD, these changes were far less evident and gallbladder function did not differ significantly from baseline.

CONCLUSION

EPBD does not adversely affect gallbladder motility in the medium-term (2 years). In terms of gallbladder motility, EPBD does not appear to increase the future risk of acute cholecystitis or gallbladder stone formation.

Review article: gall-bladder motility after intestinal surgery

There is a close relationship in humans between gall-bladder motility and gastrointestinal motility during the fasting state, as well as in the post-prandial period. Only a minority of publications take this relationship into account in the description of biliary dysmotility after various surgical procedures. Most publications deal with post-prandial gall-bladder motility or with stimulation of gall-bladder contraction from various prokinetic drugs or gastrointestinal hormones. Impaired gall-bladder motility has been demonstrated after Billroth II gastric resection, pyloroplasty and colectomy, but the epidemiological data on the risk of gallstone formation in these patients are too scarce and equivocal to recommend prophylactic cholecystectomy. Future studies on gall-bladder motility after surgical procedures should include measurements of gall-bladder motility during the fasting state, as well as in the post-prandial period. The measurements should be related to the migrating motor complexes, and this necessitates a simultaneous recording of gastrointestinal motility.

Does endoscopic papillary balloon dilation affect gallbladder motility?

BACKGROUND

Endoscopic papillary balloon dilation for treatment of bile duct stones is likely to preserve papillary function. However, endoscopic papillary balloon dilation may affect gallbladder motility. We investigated the effects of endoscopic papillary balloon dilation on gallbladder motility.

METHODS

Ten patients with an intact gallbladder (six with and four without gallbladder stones) who underwent endoscopic papillary balloon dilation for choledocholithiasis were studied. Gallbladder motility was examined before and 7 days and 1 month after endoscopic papillary balloon dilation. Gallbladder volume, while fasting and after dried egg yolk ingestion, was determined by ultrasonography.

RESULTS

Before endoscopic papillary balloon dilation, particularly in patients with gallbladder stones, the gallbladder showed significantly larger fasting volume and lower yolk-stimulated maximum contraction compared with control subjects. Seven days after endoscopic papillary balloon dilation, fasting volume was decreased and maximum contraction was increased, regardless of the presence of gallbladder stones, with significant differences from the values before endoscopic papillary balloon dilation. One month after endoscopic papillary balloon dilation, these changes were reduced and gallbladder function did not differ significantly from baseline.

CONCLUSIONS

After endoscopic papillary balloon dilation, gallbladder motility improves transiently at 7 days but returns to baseline at 1 month. In terms of gallbladder motility, endoscopic papillary balloon dilation does not seem to increase the subsequent risk of acute cholecystitis.

Biliary Tract Dysmotility

Biliary pain resulting from motility disorders is common and may be overlooked due to the difficulty of diagnosing the presence of these disorders. A sound, logical approach to the evaluation and treatment of these specific groups of disorders is essential. In patients who have a gallbladder, we initially exclude the presence of gallstones by use of transcutaneous ultrasonography. If a patient's symptoms are atypical, we initiate therapy (eg, antispasmodics) for irritable bowel syndrome. Subsequently, we perform a quantitative cholescintigraphy with a low-dose infusion of cholecystokinin in patients with typical symptoms and in those with persistent atypical symptoms. Those patients who have abnormally low gallbladder ejection fractions are subsequently referred for laparoscopic cholecystectomy. In postcholecystectomy patients, a standard approach should include obtaining serum liver associated laboratory chemistries, amylase and lipase levels, and a transcutaneous ultrasound to measure bile duct size. Endoscopic retrograde cholangiopancreatography (ERCP) is done to measure bile duct size, assess biliary duct emptying, and exclude other etiologies for pain. In patients with more than two abnormal findings on these tests (type I sphincter of Oddi dyskinesia), we recommend performing an empiric endoscopic biliary sphincterotomy. In patients with no objective abnormalities (type III sphincter of Oddi dyskinesia), it is appropriate to begin medical therapy with antispasmodics and calcium-channel antagonists. In individuals who have one or two abnormalities (type II sphincter of Oddi dyskinesia) we prefer endoscopic biliary sphincterotomy; however, these individuals are offered the opportunity to have endoscopic biliary manometry performed in order to establish a clear diagnosis. If patients refuse this procedure, after careful explanation of risks, alternatives, and possible benefits of the procedure, empiric endoscopic biliary sphincterotomy is performed.

Bile lithogenicity and gallbladder emptying in patients with microlithiasis: effect of bile acid therapy

BACKGROUND & AIMS

Biliary cholesterol supersaturation, rapid nucleation of cholesterol, and altered gallbladder motility are prerequisite for gallstone formation. However, the pathogenesis of microlithiasis is not clear. The aim of this study was to determine the abnormalities of gallbladder emptying and bile composition in patients with microlithiasis.

METHODS

Nucleation time, cholesterol saturation index (CSI), and gallbladder emptying were studied in patients with microlithiasis (n = 10), patients with gallstones (n = 10), and healthy volunteers (n = 10). Bile analysis was repeated in 6 patients with microlithiasis treated with ursodeoxycholic acid (UDCA) for 8 weeks.

RESULTS

Nucleation time was shorter in patients with microlithiasis and those with gallstones than in healthy volunteers (P < 0.0001). Patients with microlithiasis had longer nucleation time than those with gallstones (P < 0.001). There was no difference in cholesterol levels and CSI in gallstone and microlithiasis patients. However, healthy volunteers had lower cholesterol levels (P < 0.01) and CSI (P < 0.01). Patients with microlithiasis had prolongation of nucleation time (P < 0.001) and lowering of CSI (P < 0.001) after UDCA therapy. Gallbladder ejection fraction was higher in microlithiasis patients than in gallstone patients (P < 0.01) but lower than in healthy volunteers (P < 0.01).

CONCLUSIONS

Patients with microlithiasis have longer nucleation time and better gallbladder emptying than patients with gallstones. Bile abnormalities can be successfully corrected with UDCA therapy in patients with microlithiasis.