Humoral mechanisms and clinical aspects of biliary tract motility

Cholecystokinin-cholescintigraphy in adults: consensus recommendations of an interdisciplinary panel

BACKGROUND AND AIMS

Cholecystokinin-cholescintigraphy (CCK-CS) provides a physiologic, noninvasive, and quantitative method for assessing gallbladder contraction and calculation of a gallbladder ejection fraction (GBEF). At present, it is used most commonly to identify patients with suspected functional gallbladder disorder. However, the methodology of CCK infusion and normal values differ markedly among imaging centers.

METHODS

This document represents the consensus opinion of an interdisciplinary panel that gathered to assess the current optimal method for performing CCK-CS in adults, potential uses and limitations of CCK-CS, and questions that require further investigation.

RESULTS

The panel recommended the use of a single, standardized, recently described CCK-CS protocol that involves infusion of 0.02 μg/kg of sincalide over 60 minutes with a normal GBEF defined as ≥38%. The panel emphasized the need for a large, multicenter, prospective clinical trial to establish the utility of CCK-CS in the diagnosis of functional gallbladder disease. Although not without controversy regarding its clinical utility, the primary indication for CCK-CS at present is the well-selected patient with suspected functional gallbladder disorder.

CONCLUSION

Agreement was reached that the adoption of this standardized protocol is critical to improve how CCK-CS is used to direct patient care and will represent an improvement over the diverse methods currently in use by eliminating the current lack of uniformity and adding both reliability and credibility to the results.

Evaluation of gastrointestinal pathology and treatment in children with suspected biliary dyskinesia

AIM

Decreased gallbladder ejection fraction (GBEF) was reported in patients who had abdominal pain and gastrointestinal (GI) diseases. The study aims were to review pathology of GI tract in children with acalculous biliary-type abdominal pain and to evaluate the pain improvement after a 2-week trial of proton pump inhibitor (PPI) and laparoscopic cholecystectomy (LC).

METHODS

Children below 18 years of age with a history of biliary-type abdominal pain by ROME III criteria were evaluated. All underwent an upper endoscopy and their histologic findings of the proximal GI tract were reviewed. Responses to a 2-week trial of PPI and LC were analyzed.

RESULTS

Sixteen were identified with biliary-type abdominal pain with GBEF <35%. Endoscopic and histologic evidence of reflux esophagitis was observed in 11 children those of gastritis in 3 children. A GI pathology of these children is mostly acid-related and four of ten children experienced a complete response to PPIs and did not require LC. Nine children had LC; four had complete and four had partial pain improvement.

CONCLUSION

A trial of PPIs may be cost-effective prior to considering LC in these patients since four of ten children experienced a complete response to PPIs without the requirement of LC, compared with four of nine children who improved completely.

Gallbladder dyskinesia

The most appropriate means to diagnose and manage patients with suspected gallbladder dyskinesia remain contentious. A major problem relates to difficulties in clearly identifying the features that characterize biliary-like pain. Conflicting reports in the literature regarding whether symptoms alone are reliable predictors of pain relief after cholecystectomy in patients with suspected gallbladder dysfunction underscore the perceived need by clinicians for a reliable test to help confirm a clinical suspicion of gallbladder dysfunction before cholecystectomy. Most studies report use of cholecystokinin-cholescintigraphy (CCK-CS) with calculation of gallbladder ejection fraction in predicting symptom outcome after cholecystectomy in patients with suspected gallbladder dyskinesia. However, quality evidence is lacking, thereby precluding a definitive recommendation regarding its use. Nevertheless, CCK-CS may be useful when performed using a slow infusion of CCK in a well-selected patient population. Based on our clinical experience and interpretation of the literature, we currently suggest consideration of cholecystectomy to our patients based on high clinical suspicion. This is performed after adequate follow-up with trials of pharmacologic therapies and exclusion of other disease entities and counseling the patient on postoperative expectations. Clearly, a large, prospective, controlled study is needed with patients meeting the Rome definition of gallbladder dyskinesia, randomized to surgery or no surgery, and using standardized CCK-CS methods and outcome measures with long-term follow-up. This study would help us better understand the pathophysiology and optimal management of this clinically challenging condition.

Cholecystokinin-cholescintigraphy in adults: consensus recommendations of an interdisciplinary panel

BACKGROUND & AIMS

Cholecystokinin-cholescintigraphy (CCK-CS) provides a physiologic, noninvasive, and quantitative method for assessing gallbladder contraction and calculation of a gallbladder ejection fraction (GBEF). At present, it is used most commonly to identify patients with suspected functional gallbladder disorder. However, the methodology of CCK infusion and normal values differ markedly among imaging centers.

METHODS

This document represents the consensus opinion of an interdisciplinary panel that gathered to assess the current optimal method for performing CCK-CS in adults, potential uses and limitations of CCK-CS, and questions that require further investigation.

RESULTS

The panel recommended the use of a single, standardized, recently described CCK-CS protocol that involves infusion of 0.02 μg/kg of sincalide over 60 minutes with a normal gallbladder ejection fraction defined as ≥38%. The panel emphasized the need for a large, multicenter, prospective clinical trial to establish the utility of CCK-CS in the diagnosis of functional gallbladder disease. Although not without controversy regarding its clinical utility, the primary indication for CCK-CS at present is the well-selected patient with suspected functional gallbladder disorder.

CONCLUSIONS

Agreement was reached that the adoption of this standardized protocol is critical to improve how CCK-CS is used to direct patient care and will represent an improvement over the diverse methods currently in use by eliminating the current lack of uniformity and adding both reliability and credibility to the results.

Evaluation and management of functional biliary pain in patients with an intact gallbladder

The diagnosis and management of suspected functional biliary pain in patients with an intact gallbladder remains contentious. Major issues include the lack of a clear definition of what constitutes biliary pain, a poor understanding of its natural history and pathophysiology, and the all too common scenario of the patient who has persistent pain despite surgical removal of the gallbladder. As a consequence, symptoms alone have generally been considered to be unreliable in the diagnosis of gallbladder dysfunction, and this has led to a search for a reliable test to help confirm a clinical suspicion of gallbladder dysfunction prior to the definitive treatment, cholecystectomy. At present, cholecystokinin-cholescintigraphy with a calculation of the gallbladder ejection fraction is the most commonly used test; however, its utility in predicting symptom outcome after cholecystectomy has been questioned. The use of cholecystokinin-cholescintigraphy to determine the appropriateness for cholecystectomy appears to be most useful when performed using a slow infusion of cholecystokinin in a well-selected patient population. However, for reasons explained herein, consideration of cholecystectomy on the basis of high clinical suspicion after adequate follow-up with trials of pharmacological therapies and exclusion of other disease entities, together with counseling the patient on postoperative expectations, may be a reasonable alternative.

Biliary dyskinesia in pediatrics

Biliary dyskinesia is a potential cause for acalculous biliary colic in pediatric patients. A triad of symptoms and signs, consisting of abdominal pain (with or without associated nausea or fatty food intolerance), absence of gallstones, and an abnormally low cholecystokinin-stimulated gallbladder ejection fraction is used to diagnose the disorder. In several small pediatric case series, cholecystectomy resulted in symptomatic improvement in a majority of patients with biliary dyskinesia. However, the diagnosis of biliary dyskinesia and appropriate management remain controversial. This review discusses the purported pathophysiology of biliary dyskinesia and the data available regarding diagnosis and treatment of this entity in the pediatric population.

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Using kinematic MR cholangiopancreatography to evaluate biliary dilatation

OBJECTIVE

The purpose of this study was to evaluate the usefulness of kinematic MR cholangiopancreatographic (MRCP) images as an aid in predicting the need for intervention in patients with biliary dilatation.

SUBJECTS AND METHODS

Fifty patients with suspected pancreaticobiliary disorders were separated into three groups. Group I patients had biliary dilatation with periampullary lesions (n = 16), group II patients had supraampullary obstructive lesions (n = 17), and group III patients had biliary dilatation without obstruction (n = 17). Twenty consecutive single thick-slice MRCP images were obtained in the 15 degrees or 30 degrees left anterior oblique coronal plane. Two radiologists jointly reviewed the images without knowledge of the final diagnosis. The numbers of images showing relaxation of the sphincteric segment and the configuration of the distal margin of the common bile duct for the three groups were compared.

RESULTS

Relaxation of the sphincteric segment was observed on the images of only two patients (12%) in group I but on the images of all patients in groups II and III, although not on all images. Lack of visualization of sphincteric relaxation on the kinematic MRCP images had a sensitivity of 88% and a specificity of 100% for the diagnosis of periampullary lesions. Most patients whose images did not show sphincteric relaxation required biliary intervention at the sphincter level.

CONCLUSION

Nonvisualization of sphincteric relaxation on kinematic MRCP indicates ampullary or periampullary lesions. Kinematic MRCP can be used to determine the necessity of biliary intervention in patients with biliary dilatation.

Biliary sphincter motility after neural isolation of the pancreatoduodenal region in conscious dogs

BACKGROUND

Several neural and hormonal factors are known to affect the motility of the sphincter of Oddi. However, the precise mechanisms of the control of sphincter motility have not been completely explored. We investigated the relationship of canine biliary sphincter motility when it is extrinsically denervated by neural isolation of the pancreatoduodenal region.

METHODS

Interdigestive and postprandial sphincter motility in a denervated pancreatoduodenal segment and effects of cholecystokinin-octapeptide were studied in 7 conscious dogs. Data were compared with those of 7 neurally intact control dogs.

RESULTS

After extrinsic denervation of the pancreatoduodenal region, sphincter motility exerted a cyclic change in concert with the duodenal myoelectric cycles; this change involved short cyclic bursts of motor activity, which gradually increased in intensity. The increase in the cyclic bursts of motor activity was also cyclic and associated with an increase in the plasma motilin concentration. Neural isolation of the pancreatoduodenal region increased sphincter basal pressure and motility index (integral per minute). In the denervated biliary sphincter, the feeding pattern and temporary inhibitory effect of feeding, as seen in controls, were absent, which suggests the role of extrinsic nerves in delivering bile into the duodenum after feeding. In the denervated dogs, cholecystokinin-octapeptide caused excitation of the sphincter activity, instead of relaxation observed in controls.

CONCLUSIONS

Extrinsic innervation to the pancreatoduodenal region has an inhibitory effect on biliary sphincter motility. Abnormalities in extrinsic innervation to the biliary sphincter might increase the resistance of the sphincter to the bile flow and induce bile stagnation.

Gallbladder hypomotility in diabetic polyneuropathy

This study was performed to evaluate the gallbladder motility in long-standing diabetes mellitus. The gallbladder function of diabetic patients was measured by means of quantitative hepatobiliary scintigraphy, and the severity of the associated autonomic and sensory polyneuropathy was determined. The presence of a marked gallbladder hypomotility was established, and a positive correlation was observed between the severity of the autonomic disturbance and the contractile disorder. This study underlines the important role of the neuropathy in the development of gallbladder hypomotility accompanying long-term diabetes mellitus.