1
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Richmond BK. Biliary Dyskinesia-Controversies, Diagnosis, and Management: A Review. JAMA Surg 2024:2820785. [PMID: 38959007 DOI: 10.1001/jamasurg.2024.0818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
Importance Biliary dyskinesia is a disorder characterized by biliary pain, a sonographically normal gallbladder, and a reduced gallbladder ejection fraction on cholecystokinin-cholescintigraphy (CCK-HIDA) scan. Laparoscopic cholecystectomy remains a common treatment for biliary dyskinesia despite a lack of high-quality evidence supporting the practice. The following review summarizes the current biliary dyskinesia outcomes data, the diagnostic strategies and their limitations, biliary dyskinesia in the pediatric population, the emerging phenomenon of the hyperkinetic gallbladder, and suggestions for addressing identified knowledge gaps. Observations The majority of studies on the topic are retrospective, with wide variations in inclusion criteria and definition of biliary pain. Most report a very short follow-up interval, often a single office visit, with variable and nonstandardized definitions of a satisfactory outcome. Despite a published Society of Nuclear Medicine guideline for its performance, CCK-HIDA scan protocols vary among institutions, which has led to considerable variability in the consistency and reproducibility of CCK-HIDA results. The few prospective studies available, although small and heterogeneous, support a role for cholecystectomy in the treatment of adult biliary dyskinesia. Despite these knowledge gaps, biliary dyskinesia is now the number 1 indication for cholecystectomy in children. Cholecystectomy for the hyperkinetic gallbladder appears to be an emerging phenomenon, despite, as in biliary dyskinesia, a lack of quality data supporting this practice. Randomized trials addressing these gaps are needed but have been difficult to conduct owing to strong clinician and patient bias toward surgery and the lack of a criterion-standard nonsurgical treatment for the control arm. Conclusions and Relevance The use of cholecystectomy for adult biliary dyskinesia is reasonable based on the available data. Insufficient data exist regarding laparoscopic cholecystectomy for pediatric dyskinesia and the hyperkinetic gallbladder population. Large-scale prospective studies, either randomized trials or large prospectively followed cohort studies, are needed to address the knowledge gaps surrounding this controversial diagnosis.
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Affiliation(s)
- Bryan K Richmond
- Department of Surgery, West Virginia University/Charleston Division, Charleston Area Medical Center Institute for Academic Medicine, Charleston
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2
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Peacock JG, Adams AM. Fatty Meal Hepatobiliary Scintigraphy for Gallbladder Ejection Fraction Determination. J Nucl Med Technol 2024; 52:21-23. [PMID: 38443104 DOI: 10.2967/jnmt.123.266790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
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3
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Peacock JG, Hayes HA, Connor TD. Use of a Fatty Meal Cholecystagogue Protocol in Hepatobiliary Scintigraphy for Chronic Functional Gallbladder Disease. J Nucl Med Technol 2024; 52:15-20. [PMID: 38443112 PMCID: PMC10924151 DOI: 10.2967/jnmt.123.266789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/09/2023] [Indexed: 03/07/2024] Open
Abstract
Chronic functional gallbladder disorder, characterized by biliary pain in the absence of structural pathology, poses a diagnostic challenge necessitating reliable cholecystagogues for accurate evaluation. However, recurrent shortages of synthetic cholecystokinin analogs have prompted the exploration of alternative agents. This paper describes the efficacy of Ensure Plus as a viable fatty meal substitute for hepatobiliary scintigraphy in assessing chronic functional gallbladder disorder. Through comparative studies, Ensure Plus demonstrates comparable diagnostic accuracy to cholecystokinin in similar patient populations. Furthermore, Ensure Plus demonstrates significant symptom improvement after cholecystectomy in patients with anomalous gallbladder ejection fractions. This paper offers a detailed protocol for the seamless integration of Ensure Plus into hepatobiliary scintigraphy, providing clinicians with a valuable tool to navigate cholecystokinin shortages while maintaining diagnostic precision in cases of chronic functional gallbladder disorder. The use of Ensure Plus not only addresses practical supply challenges but also underscores its potential as a cost-effective and clinically sound alternative in biliary diagnostics.
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Affiliation(s)
- Justin G Peacock
- Department of Radiology and the Radiological Sciences, Uniformed Services University, Bethesda, Maryland;
- Department of Military Medical Operations, Armed Forces Radiobiology Research Institute, Bethesda, Maryland; and
| | - Horace A Hayes
- Department of Radiology, Brooke Army Medical Center, San Antonio, Texas
| | - Tylor D Connor
- Department of Radiology, Brooke Army Medical Center, San Antonio, Texas
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4
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Jang SI, Lee TH, Jeong S, Kwon CI, Koh DH, Kim YJ, Lee HS, Do MY, Cho JH, Lee DK. Efficacy of Chenodeoxycholic Acid and Ursodeoxycholic Acid Treatments for Refractory Functional Dyspepsia. J Clin Med 2022; 11:jcm11113190. [PMID: 35683573 PMCID: PMC9181150 DOI: 10.3390/jcm11113190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 11/16/2022] Open
Abstract
Refractory functional dyspepsia (RFD) is diagnosed when symptoms persist for at least 6 months despite at least two medical treatments. No consensus treatment guidelines exist. The implicated causes of functional biliary dyspepsia are a narrowed cystic duct, Sphincter of Oddi dysfunction, microlithiasis, and gallbladder dyskinesia. We investigated the treatment effects of litholytic agents. RFD patients were prospectively enrolled in six tertiary medical centers. All subjects took chenodeoxycholic and ursodeoxycholic acids (CNU) twice daily for 12 weeks. We monitored their medication adherence, laboratory results, and complications. The 7-point global symptom scale test scores were determined before and after treatment. Of the 52 patients who were prospectively screened, 37 were included in the final analysis. The mean age was 51.3 years: 14 were males, and 23 were females. Before treatment, the mean number and duration of symptoms were 2.4 and 48.2 months, and a mean of 3.3 FD-related drugs were taken. The mean CNU adherence was 95.3%. The mean global symptom scale score decreased from 5.6 pretreatment to 2.6 posttreatment. The symptom improvement rate was 94.6% (35 out of 37 patients). The only adverse event was mild diarrhea (10.8%) that was resolved after conservative management. Conclusions: CNU improved the symptoms of RFD patients who did not respond to conventional medications. Litholytic agents are good treatment options for patients with RFD and biliary dyspepsia secondary to biliary microlithiasis. Further prospective, large-scale mechanistic studies are warranted.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (S.I.J.); (M.-Y.D.); (D.K.L.)
| | - Tae Hoon Lee
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan 31151, Korea;
| | - Seok Jeong
- Department of Internal Medicine, Inha University School of Medicine, Incheon 22332, Korea;
| | - Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam 13496, Korea;
| | - Dong Hee Koh
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea;
| | - Yoon Jae Kim
- Department of Internal Medicine, Gachon University College of Medicine, Gil Medical Center, Incheon 21565, Korea;
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul 06273, Korea;
| | - Min-Young Do
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (S.I.J.); (M.-Y.D.); (D.K.L.)
| | - Jae Hee Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (S.I.J.); (M.-Y.D.); (D.K.L.)
- Correspondence:
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (S.I.J.); (M.-Y.D.); (D.K.L.)
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5
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Richmond BK, Walker A. Biliary Dyskinesia: Current Perspectives and Future Directions. Am Surg 2020; 87:954-960. [PMID: 33295186 DOI: 10.1177/0003134820971617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Biliary dyskinesia (BD) is a disorder characterized by functional biliary pain, the absence of gallstones on ultrasound, and the finding of a reduced gallbladder ejection fraction on a cholecystokinin-cholescintigraphic scan. Cholecystectomy remains a commonly applied treatment for BD, despite a lack of high-quality evidence supporting the practice. The following article provides an overview of the current diagnostic strategies, treatment outcomes with both surgical and nonsurgical treatment, emerging considerations related to special populations, and suggestions for addressing the identified knowledge gaps, moving forward in an effort to develop stronger, more evidence-based practice guidelines for treating this poorly understood and poorly studied condition.
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Affiliation(s)
- Bryan K Richmond
- Department of Surgery, West Virginia University/Charleston Division, USA
| | - Andrew Walker
- Department of Surgery, West Virginia University/Charleston Division, USA
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6
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Flick KF, Soufi M, Sublette CM, Sinsabaugh CA, Colgate CL, Tann M, House MG. Optimal hepatobiliary scintigraphy for gallbladder dyskinesia. Surg Open Sci 2020; 4:7-11. [PMID: 33569543 PMCID: PMC7847953 DOI: 10.1016/j.sopen.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/10/2020] [Accepted: 10/17/2020] [Indexed: 12/03/2022] Open
Abstract
Background The accuracy of hepatobiliary scintigraphy to assess gallbladder function remains controversial. National supply shortages of pharmaceutical-grade cholecystokinin led to the use of an oral fatty meal to stimulate gallbladder contraction during hepatobiliary scintigraphy. The goal of this study was to compare the predictive indices of cholecystokinin and fatty meal ingestion for stimulation of gallbladder contraction. Methods Patients evaluated with hepatobiliary iminodiacetic acid scan from 2014 to 2017 were reviewed and grouped based on testing stimulant (fatty meal versus cholecystokinin). Patients who later underwent cholecystectomy were selected for analysis. Hepatobiliary iminodiacetic acid results were correlated with surgical pathology and postoperative resolution of symptoms. Two-way statistical analysis was performed. Results A total of 359 patients underwent hepatobiliary iminodiacetic acid scan followed by cholecystectomy for biliary dyskinesia. Patients who received fatty meal stimulant (n = 86) were compared to those that received cholecystokinin (n = 273). Mean gallbladder ejection fraction during hepatobiliary iminodiacetic acid was 38% and 44% for the cholecystokinin and fatty meal groups, respectively, P = .073. Predictive metrics were not statistically different between groups with regard to pathology, symptomatic improvement, or accuracy. Symptomatic resolution (cholecystokinin–hepatobiliary iminodiacetic acid 78%, fatty meal–hepatobiliary iminodiacetic acid 68%; P = 0.058) and specificity (cholecystokinin–hepatobiliary iminodiacetic acid 26%, fatty meal–hepatobiliary iminodiacetic acid 44%, P = 0.417) were comparable in both testing groups. Conclusion Stimulation of gallbladder contraction with a fatty meal during hepatobiliary iminodiacetic acid testing is a more affordable and reliable alternative to cholecystokinin for patients undergoing evaluation for gallbladder dysmotility. Use of a fatty meal as a stimulant for hepatobiliary iminodiacetic acid scan. Affordable alternative to cholecystokinin for a hepatobiliary iminodiacetic acid scan. Comparison of 2 stimulants used for hepatobiliary iminodiacetic acid scan. Reliable alternative to IV cholecystokinin for hepatobiliary iminodiacetic acid scans.
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Affiliation(s)
- K F Flick
- Department of Surgery, Indianapolis, IN
| | - M Soufi
- Department of Surgery, Indianapolis, IN
| | - C M Sublette
- Indiana University School of Medicine, Indianapolis, IN
| | - C A Sinsabaugh
- Department of Radiology and Imaging Sciences, Indianapolis, IN
| | - C L Colgate
- Center for Outcomes Research in Surgery, Indianapolis, IN
| | - M Tann
- Department of Radiology and Imaging Sciences, Indianapolis, IN
| | - M G House
- Department of Surgery, Indianapolis, IN
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7
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Abstract
Nearly 20,000 pediatric patients undergo cholecystectomy annually, and abnormal gallbladder emptying ("biliary dyskinesia") has replaced cholelithiasis as the leading indication for this operation in the USA. Nonetheless, patients with abnormal gallbladder emptying nuclear medicine scans do not uniformly benefit from cholecystectomy. This article reviews the available data on presentation, workup and treatment of patients with abnormally low and high rates of gallbladder emptying.
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Affiliation(s)
- M Coluccio
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, 818 Ellicott St, Buffalo, New York, 14203, USA
| | - A J Claffey
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, 818 Ellicott St, Buffalo, New York, 14203, USA
| | - D H Rothstein
- Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, 818 Ellicott St, Buffalo, New York, 14203, USA; Department of Pediatric Surgery, John R. Oishei Children's Hospital, 818 Ellicott St, Buffalo, New York, 14203, USA.
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8
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Eiken A, Fuglsang S, Eiken M, Svane MS, Kuhre RE, Wewer Albrechtsen NJ, Hansen SH, Trammell SAJ, Svenningsen JS, Rehfeld JF, Bojsen-Møller KN, Jørgensen NB, Holst JJ, Madsbad S, Madsen JL, Dirksen C. Bilio-enteric flow and plasma concentrations of bile acids after gastric bypass and sleeve gastrectomy. Int J Obes (Lond) 2020; 44:1872-1883. [PMID: 32317753 DOI: 10.1038/s41366-020-0578-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 03/04/2020] [Accepted: 03/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND/OBJECTIVES Bile acids in plasma are elevated after bariatric surgery and may contribute to metabolic improvements, but underlying changes in bile flow are poorly understood. We assessed bilio-enteric flow of bile and plasma bile concentrations in individuals with Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) surgery compared with matched non-surgical controls (CON). SUBJECTS/METHODS Fifteen RYGB, 10 SG and 15 CON underwent 99Tc-mebrofenin cholescintigraphy combined with intake of a high-fat 111In-DTPA-labelled meal and frequent blood sampling. A 75Se-HCAT test was used to assess bile acid retention. RESULTS After RYGB, gallbladder filling was decreased (p = 0.045 versus CON), basal flow of bile into the small intestine increased (p = 0.005), bile acid retention augmented (p = 0.021) and basal bile acid plasma concentrations elevated (p = 0.009). During the meal, foods passed unimpeded through the gastric pouch resulting in almost instant postprandial mixing of bile and foods, but the postprandial rise in plasma bile acids was brief and associated with decreased overall release of fibroblast growth factor-19 (FGF-19) compared with CON (p = 0.033). After SG, bile flow and retention were largely unaltered (p > 0.05 versus CON), but gastric emptying was accelerated (p < 0.001) causing earlier mixture of bile and foods also in this group. Neither basal nor postprandial bile acid concentrations differed between SG and CON. CONCLUSIONS Bilio-enteric bile flow is markedly altered after RYGB resulting in changes in plasma concentrations of bile acids and FGF-19, whereas bile flow and plasma concentrations are largely unaltered after SG.
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Affiliation(s)
- Aleksander Eiken
- Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark
| | - Stefan Fuglsang
- Department of Clinical Physiology and Nuclear Medicine, Centre for Functional Imaging and Research, Hvidovre Hospital, Hvidovre, Denmark
| | - Markus Eiken
- Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark
| | - Maria S Svane
- Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark
| | - Rune E Kuhre
- NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai J Wewer Albrechtsen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,NNF Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department. of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | - Svend H Hansen
- Department. of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | - Samuel A J Trammell
- NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens S Svenningsen
- NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens F Rehfeld
- Department. of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | | | - Nils B Jørgensen
- Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark
| | - Jens J Holst
- NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark
| | - Jan L Madsen
- Department of Clinical Physiology and Nuclear Medicine, Centre for Functional Imaging and Research, Hvidovre Hospital, Hvidovre, Denmark
| | - Carsten Dirksen
- Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark.
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9
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Scintigraphy of the Liver, Spleen, and Biliary Tree. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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10
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Miller LJ, Harikumar KG, Desai AJ, Siddiki H, Nguyen BD. Kinetics of Gallbladder Emptying During Cholecystokinin Cholescintigraphy as an Indicator of In Vivo Hormonal Sensitivity. J Nucl Med Technol 2019; 48:40-45. [PMID: 31604888 DOI: 10.2967/jnmt.119.233486] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 08/12/2019] [Indexed: 12/15/2022] Open
Abstract
Cholecystokinin cholescintigraphy is used clinically to quantify gallbladder ejection fraction as an indicator of functional gallbladder disorder. It can also provide the opportunity to quantify an individual's responsiveness to the physiologic stimulant of gallbladder contraction, cholecystokinin, which is a major regulator of appetite and postprandial satiety. Methods: In the current work, we use cholecystokinin cholescintigraphy to quantify the kinetics of gallbladder emptying, including average and peak rates, in response to a standard cholecystokinin infusion. Results: We demonstrated that patients with no gallstones or biliary obstruction who empty their gallbladders completely in response to cholecystokinin, having an ejection fraction greater than 80%, exhibit a broad range of sensitivity to this hormone. Three distinct kinetic profiles were observed, with those most sensitive to cholecystokinin achieving the earliest peak and the fastest rate of gallbladder emptying, whereas those least sensitive to cholecystokinin have the latest peak and the slowest rate of emptying. Conclusion: Patients can have abnormal cholecystokinin stimulus-activity coupling as an effect of endogenous negative allosteric modulation by membrane cholesterol. This was predicted in ex vivo studies but has not, to our knowledge, previously been demonstrated in vivo. This type of kinetic analysis provides a tool to quantify cholecystokinin responsiveness in patients and identify patients who might benefit from a drug that would positively modulate cholecystokinin action to improve their appetite regulation and to better control their weight.
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Affiliation(s)
- Laurence J Miller
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Scottsdale, Arizona .,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona; and
| | - Kaleeckal G Harikumar
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Scottsdale, Arizona.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona; and
| | - Aditya J Desai
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Scottsdale, Arizona
| | - Hassan Siddiki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona; and
| | - Ba D Nguyen
- Division of Nuclear Medicine, Department of Diagnostic Radiology, Mayo Clinic, Scottsdale, Arizona
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11
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Rehman S, Singh KK, Sajid MS. Role of laparoscopic cholecystectomy in the management of chronic right upper quadrant pain due to biliary dyskinesia: a systematic review and meta-analysis. Transl Gastroenterol Hepatol 2019; 4:71. [PMID: 31620653 DOI: 10.21037/tgh.2019.08.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 08/15/2019] [Indexed: 12/27/2022] Open
Abstract
Background The objective of this study was to evaluate the surgical outcomes and feasibility of performing laparoscopic cholecystectomy (LC) in patients with longstanding right upper quadrant pain secondary to biliary dyskinesia. Methods A systematic review of the literature including published randomized, controlled trials, non-randomized trials and comparative trials of any type, reporting outcomes of LC in the management of chronic right upper quadrant pain in patients with biliary dyskinesia, using the principles of meta-analysis on RevMan 5.3 statistical software, was undertaken. Results Thirteen studies including 740 patients evaluating the symptomatic improvement following LC in patients with biliary dyskinesia presenting as chronic right upper quadrant pain were included. There were 542 patients in LC group and 198 patients in Non-LC group. Successful complete resolution of symptoms was more likely to be achieved in LC group [risk ratio (RR), 0.21; 95% confidence interval (CI), 0.09-0.50, P=0.00001]. In addition, the risk of failure to resolve symptoms (risk ratio, 0.15; 95% CI, 0.05-0.39, P=0.00001) was lower in LC group. Conclusions LC may be considered as an acceptable surgical intervention in patients with biliary dyskinesia presenting with chronic right upper quadrant pain. Currently there is insufficient evidence to recommend the routine use of LC in every patient with biliary dyskinesia. Paucity of high power randomised, controlled trials is the major reason for this lack of evidence which should be addressed soon and until then current study may be used to provide the basis for offering LC in selected group of patients.
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Affiliation(s)
- Saad Rehman
- Department of Upper GI and Bariatric Surgery, Shrewsbury & Telford NHS Hospitals Trust, Shrewsbury, UK
| | - Krishna Kumar Singh
- Department of Gastrointestinal Surgery, Brighton & Sussex University Hospital NHS Trust, Brighton, UK
| | - Muhammad Shafique Sajid
- Department of Gastrointestinal Surgery, Brighton & Sussex University Hospital NHS Trust, Brighton, UK
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12
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Ziessman HA. Sincalide: A Review of Clinical Utility, Proper Infusion Methodology, and Alternative Cholecystogogues. J Nucl Med Technol 2019; 47:210-212. [PMID: 31019045 DOI: 10.2967/jnmt.119.226019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 02/25/2019] [Indexed: 11/16/2022] Open
Abstract
Sincalide (Kinevac) is widely used in conjunction with cholescintigraphy for a variety of clinical indications. Over the years, numerous publications have verified the optimal infusion methodology. Published data and consensus recommendations emphasize that sincalide, 0.02 μg/kg, should be infused over 60 min. Production problems sometimes limit the availability of sincalide. In that case, non-Food and Drug Administration pharmacy-compounded sincalide may serve as an alternative. Fatty meals have also been used. Various illnesses and drugs may inhibit gallbladder contraction. Thus, these drugs should be withheld for 48 h before the study. Sincalide cholescintigraphy is most commonly used to diagnose or exclude chronic acalculous gallbladder disease. The study should preferably be performed as an outpatient procedure.
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Affiliation(s)
- Harvey A Ziessman
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Maryland
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13
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Doot RK, Dubroff JG, Scheuermann JS, Labban KJ, Cai J, Hsieh CJ, Li S, Lee H, Schubert EK, Hou C, Sheffer R, Schmitz A, Xu K, Mach RH. Validation of gallbladder absorbed radiation dose reduction simulation: human dosimetry of [ 18F]fluortriopride. EJNMMI Phys 2018; 5:21. [PMID: 30294746 PMCID: PMC6174116 DOI: 10.1186/s40658-018-0219-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 06/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND [18F]Fluortriopride (FTP) was developed as a dopamine D3-selective radiotracer, thought to be important to neurobiological reward pathways and implicated in drug addiction, Parkinson's disease, and schizophrenia. Preclinical radiation dosimetry studies found the gallbladder wall received the highest dose. A gallbladder dose reduction intervention was simulated using a novel reduction model for healthy adults following fatty-meal consumption. The goals of this study were to assess whole body FTP human dosimetry and determine the feasibility of reducing absorbed dose to the gallbladder wall. RESULTS Effective dose without a fatty meal was 0.022 ± 0.002 mSv/MBq (± standard deviation) with highest organ dose of 0.436 ± 0.178 mSv/MBq to the gallbladder wall (n = 10). Predicted gallbladder dose reduction with fatty meal consumed was 67.4% (n = 10). Meal consumption by four repeat volunteers decreased average gallbladder dose by 71.3% (n = 4) compared to the original ten volunteers. CONCLUSIONS Observed effective doses were adequately low to continue studying FTP uptake in humans. Validated dosimetry simulations indicate up to a 71% reduction in gallbladder dose can be achieved by employing intrinsic physiology to contract the gallbladder via fatty meal ingestion. This methodology for predicting gallbladder absorbed dose reduction from fatty meal consumption can be applied to other radiopharmaceuticals and radiotherapies.
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Affiliation(s)
- Robert K Doot
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Jacob G Dubroff
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Joshua S Scheuermann
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Kyle J Labban
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Jenny Cai
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Chia-Ju Hsieh
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Shihong Li
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Hsiaoju Lee
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Erin K Schubert
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Catherine Hou
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Regan Sheffer
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Alexander Schmitz
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Kuiying Xu
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Robert H Mach
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
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Nakayuenyongsuk W, Choudry H, Yeung KA, Karnsakul W. Decision-making patterns in managing children with suspected biliary dyskinesia. World J Clin Pediatr 2017; 6:124-131. [PMID: 28540197 PMCID: PMC5424281 DOI: 10.5409/wjcp.v6.i2.124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/04/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To explore and to analyze the patterns in decision-making by pediatric gastroenterologists in managing a child with a suspected diagnosis of functional gallbladder disorder (FGBD).
METHODS The questionnaire survey included a case history with right upper quadrant pain and was sent to pediatric gastroenterologists worldwide via an internet list server called the PEDGI Bulletin Board.
RESULTS Differences in decision-making among respondents in managing this case were observed at each level of investigations and management. Cholecystokinin-scintigraphy scan (CCK-CS) was the most common investigation followed by an endoscopy. A proton pump inhibitor was most commonly prescribed treating the condition. The majority of respondents considered a referral for a surgical evaluation when CCK-CS showed a decreased gallbladder ejection fraction (GBEF) value with biliary-type pain during CCK injection.
CONCLUSION CCK infusion rate in CCK-CS-CS and GBEF cut-off limits were inconsistent throughout practices. The criteria for a referral to a surgeon were not uniform from one practitioner to another. A multidisciplinary team approach with pediatric gastroenterologists and surgeons is required guide the decision-making managing a child with suspected FGBD.
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Tubay M, Zelasko S. Multimodality Imaging of the Gallbladder: Spectrum of Pathology and Associated Imaging Findings. CURRENT RADIOLOGY REPORTS 2016. [DOI: 10.1007/s40134-016-0148-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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16
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Richmond BK, Grodman C, Walker J, Dean S, Tiley EH, Hamrick RE, Statler K, Emmett M. Pilot Randomized Controlled Trial of Laparoscopic Cholecystectomy vs Active Nonoperative Therapy for the Treatment of Biliary Dyskinesia. J Am Coll Surg 2016; 222:1156-63. [PMID: 27049778 DOI: 10.1016/j.jamcollsurg.2016.02.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 02/24/2016] [Accepted: 02/25/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Despite widespread adoption by the surgical community, high-quality prospective data supporting the practice of laparoscopic cholecystectomy (LC) for the treatment of biliary dyskinesia (BD) are lacking. STUDY DESIGN Adult patients meeting criteria for diagnosis of BD (Rome III symptoms, normal ultrasound, gallbladder ejection fraction < 38%) were randomized to either LC or a trial of nonoperative (NO) therapy with a low-dose neuromodulator (amitriptyline 25 mg/day). Patients in the NO arm were allowed to cross over to the surgical arm and remain in the study for any reason. Besides collection of basic demographics and medical/surgical history, patients were administered a standardized quality of life (QOL) assessment (Short Form-8) and a symptom-specific questionnaire (Rome III criteria) at enrollment and monthly through the study to assess the effect of treatment on biliary symptoms and overall QOL. RESULTS Thirty patients were enrolled over 12 months (15 LC, 15 NO). In the LC group, 13 underwent LC, 1 refused surgery, 1 withdrew. In the NO group, 14 crossed over to the LC group (13 of whom had LC), yielding 26 patients who underwent LC. The SF-8 physical scores (PCS-8) were significantly improved at both the first and last follow-up visits (p < 0.0001, p = 0.0003, respectively). The SF-8 mental scores (MCS-8) were also significantly improved at both the first and last follow-up visits (p = 0.0187, p = 0.0017, respectively). With median follow-up of 12 months (range 3 to 14 months), all 26 reported relief of pain. CONCLUSIONS This pilot study raises doubts regarding the feasibility of a randomized trial, presumably due to both clinician and patient bias toward LC and the lack of "gold-standard" nonoperative treatments. However, these prospective data indicate that, with careful patient selection (standardized symptom criteria/imaging methodology), LC results in pain relief and significant improvement in QOL in BD patients. Further prospective study of these findings is warranted.
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Affiliation(s)
- Bryan K Richmond
- Department of Surgery, West Virginia University/Charleston Division, Charleston, WV.
| | - Caresse Grodman
- Charleston Area Medical Center Health Education and Research Institute, Charleston, WV
| | - Jerri Walker
- Charleston Area Medical Center Health Education and Research Institute, Charleston, WV
| | - Scott Dean
- Charleston Area Medical Center Health Education and Research Institute, Charleston, WV
| | - Edward H Tiley
- Department of Surgery, West Virginia University/Charleston Division, Charleston, WV
| | - Roland E Hamrick
- Department of Surgery, West Virginia University/Charleston Division, Charleston, WV
| | - Kristen Statler
- Department of Surgery, West Virginia University/Charleston Division, Charleston, WV
| | - Mary Emmett
- Charleston Area Medical Center Health Education and Research Institute, Charleston, WV
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Cotton PB, Elta GH, Carter CR, Pasricha PJ, Corazziari ES. Rome IV. Gallbladder and Sphincter of Oddi Disorders. Gastroenterology 2016; 150:S0016-5085(16)00224-9. [PMID: 27144629 DOI: 10.1053/j.gastro.2016.02.033] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 12/19/2022]
Abstract
The concept that motor disorders of the gallbladder, cystic duct and sphincter of Oddi can cause painful syndromes is attractive and popular, at least in the USA. However, the results of commonly performed ablative treatments (cholecystectomy and sphincterotomy) are not uniformly good. The predictive value of tests that are often used to diagnose dysfunction (dynamic gallbladder scintigraphy and sphincter manometry) is controversial. Evaluation and management of these patients is made difficult by the fluctuating symptoms and the placebo effect of invasive interventions. A recent stringent study has shown that sphincterotomy is no better than sham treatment in patients with post-cholecystectomy pain and little or no objective abnormalities on investigation, so that the old concept of sphincter of Oddi dysfunction (SOD) type III is discarded. ERCP approaches are no longer appropriate in that context. There is a pressing need for similar prospective studies to provide better guidance for clinicians dealing with these patients. We need to clarify the indications for cholecystectomy in patients with Functional Gallbladder Disorder (FGBD) and the relevance of sphincter dysfunction in patients with some evidence for biliary obstruction (previously SOD type II, now called "Functional Biliary Sphincter Disorder - FBSD") and with idiopathic acute recurrent pancreatitis.
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Affiliation(s)
- P B Cotton
- Medical University of South Carolina, Charleston, SC, USA.
| | - G H Elta
- University of Michigan, Ann Arbor, MI, USA
| | | | - P J Pasricha
- Johns Hopkins School of Medicine, Baltimore, MD, USA
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18
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Low CS, Ahmed H, Notghi A. Pitfalls and Limitations of Radionuclide Hepatobiliary and Gastrointestinal System Imaging. Semin Nucl Med 2015; 45:513-29. [DOI: 10.1053/j.semnuclmed.2015.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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19
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Liu Y, Zhang Y, Gu Z, Hao L, Du J, Yang Q, Li S, Wang L, Gong S. Cholecystokinin octapeptide antagonizes apoptosis in human retinal pigment epithelial cells. Neural Regen Res 2014; 9:1402-8. [PMID: 25221599 PMCID: PMC4160873 DOI: 10.4103/1673-5374.137596] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2014] [Indexed: 11/13/2022] Open
Abstract
Although cholecystokinin octapeptide-8 is important for neurological function, its neuroprotective properties remain unclear. We speculated that cholecystokinin octapeptide-8 can protect human retinal pigment epithelial cells against oxidative injury. In this study, retinal pigment epithelial cells were treated with peroxynitrite to induce oxidative stress. Peroxynitrite triggered apoptosis in these cells, and increased the expression of Fas-associated death domain, Bax, caspa-se-8 and Bcl-2. These changes were suppressed by treatment with cholecystokinin octapeptide-8. These results suggest that cholecystokinin octapeptide-8 can protect human retinal pigment epithelial cells against apoptosis induced by peroxynitrite.
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Affiliation(s)
- Yuan Liu
- Department of Ophthalmology, First Central Hospital of Baoding, Baoding, Hebei Province, China
| | - Yueling Zhang
- Department of Ophthalmology, First Central Hospital of Baoding, Baoding, Hebei Province, China
| | - Zhaohui Gu
- Department of Ophthalmology, First Central Hospital of Baoding, Baoding, Hebei Province, China
| | - Lina Hao
- Department of Ophthalmology, Hebei Province People's Hospital, Shijiazhuang, Hebei Province, China
| | - Juan Du
- Department of Ophthalmology, First Central Hospital of Baoding, Baoding, Hebei Province, China
| | - Qian Yang
- Department of Ophthalmology, First Central Hospital of Baoding, Baoding, Hebei Province, China
| | - Suping Li
- Department of Ophthalmology, First Central Hospital of Baoding, Baoding, Hebei Province, China
| | - Liying Wang
- Department of Ophthalmology, First Central Hospital of Baoding, Baoding, Hebei Province, China
| | - Shilei Gong
- Department of Endoscope Room, First Central Hospital of Baoding, Baoding, Hebei Province, China
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20
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Ziessman HA. Hepatobiliary Scintigraphy in 2014. J Nucl Med 2014; 42:249-59. [DOI: 10.2967/jnumed.113.131490] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 03/03/2014] [Indexed: 01/09/2023] Open
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Abstract
Biliary dyskinesia (BD) is a diagnosis that is being made increasingly in children. It is defined by abdominal pain thought to be biliary in nature based on location and character; a completely normal gallbladder on imaging tests, typically ultrasound; and decreased gallbladder contraction in response to a pharmacological stimulus. Unlike other functional gastrointestinal disorders (FGIDs) that are treated with medications, behavioral therapy, and/or dietary modification, current clinical practice has accepted cholecystectomy as the treatment of choice for BD, which now accounts for up to 50% of cholecystectomies in children. Although well-designed trials are missing, accumulating evidence argues against such an approach. First, BD is by definition a benign disorder without risk of truly relevant complications. Second, despite reportedly high rates of satisfaction with postoperative outcomes, most children continue to experience symptoms. Lastly, limited long-term studies have demonstrated comparable benefit of operative and conservative therapy. To summarize, BD should be seen as a more localized manifestation of functional abdominal pain, which may improve over time independent of the type of therapy chosen. Despite the widespread adoption of minimally invasive surgery in pediatrics, a different risk-benefit ratio favors conservative treatment for this benign disorder.
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Abstract
Symptomatic cholelithiasis and functional disorders of the biliary tract present with similar signs and symptoms. The functional disorders of the biliary tract include functional gallbladder disorder, dyskinesia, and the sphincter of Oddi disorders. Although the diagnosis and treatment of symptomatic cholelithiasis are relatively straightforward, the diagnosis and treatment of functional disorders can be much more challenging. Many aspects of the diagnosis and treatment of functional disorders are in need of further study. This article discusses uncomplicated gallstone disease and the functional disorders of the biliary tract to emphasize and update the essential components of diagnosis and management.
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Tewari SO, Petre EN, Osborne J, Sofocleous CT. Cholecystokinin-Assisted Hydrodissection of the Gallbladder Fossa during FDG PET/CT-guided Liver Ablation. Cardiovasc Intervent Radiol 2013; 36:1704-1706. [DOI: 10.1007/s00270-013-0692-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 06/05/2013] [Indexed: 11/24/2022]
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Utilization of cholecystokinin cholescintigraphy in clinical practice. J Am Coll Surg 2013; 217:317-23. [PMID: 23731969 DOI: 10.1016/j.jamcollsurg.2013.02.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 02/27/2013] [Indexed: 02/07/2023]
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