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Kulaylat AN, Lucas DJ, Chang HL, Derderian SC, Beres AL, Ham PB, Huerta CT, Sulkowski JP, Wakeman D, Englum BR, Gulack BC, Acker SN, Gonzalez KW, Levene TL, Christison-Lagay E, Mansfield SA, Yousef Y, Pennell CP, Russell KW, Rentea RM, Tashiro J, Diesen DL, Alemayehu H, Ricca R, Kelley-Quon L, Rialon KL. Evaluation and Management of Biliary Dyskinesia in Children and Adolescents: A Systematic Review From the APSA Outcomes and Evidence-Based Committee. J Pediatr Surg 2024:161678. [PMID: 39227244 DOI: 10.1016/j.jpedsurg.2024.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 08/05/2024] [Indexed: 09/05/2024]
Abstract
INTRODUCTION The diagnosis and management of biliary dyskinesia in children and adolescents remains variable and controversial. The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee (APSA OEBP) performed a systematic review of the literature to develop evidence-based recommendations. METHODS Through an iterative process, the membership of the APSA OEBP developed five a priori questions focused on diagnostic criteria, indications for cholecystectomy, short and long-term outcomes, predictors of success/benefit, and outcomes of medical management. A systematic review was conducted, and articles were selected for review following Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. Risk of bias was assessed using Methodologic Index for Non-Randomized Studies (MINORS) criteria. The Oxford Levels of Evidence and Grades of Recommendation were utilized. RESULTS The diagnostic criteria for biliary dyskinesia in children and adolescents are not clearly defined. Cholecystectomy may provide long-term partial or complete relief in some patients; however, there are no reliable predictors of symptom relief. Some patients may experience resolution of symptoms with non-operative management. CONCLUSIONS Pediatric biliary dyskinesia remains an ill-defined clinical entity. Pediatric-specific guidelines are necessary to better characterize the condition, guide work-up, and provide management recommendations. Prospective studies are necessary to more reliably identify patients who may benefit from cholecystectomy. LEVEL OF EVIDENCE Level 3-4. TYPE OF STUDY Systematic Review of Level 3-4 Studies.
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Affiliation(s)
- Afif N Kulaylat
- Penn State Children's Hospital, Division of Pediatric Surgery, Hershey, PA, USA.
| | - Donald J Lucas
- Division of Pediatric Surgery, Naval Medical Center, San Diego, CA, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Henry L Chang
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - S Christopher Derderian
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Alana L Beres
- St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
| | - P Benson Ham
- Division of Pediatric Surgery, John R. Oishei Children's Hospital of Buffalo, University at Buffalo, Buffalo, NY, USA
| | - Carlos T Huerta
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jason P Sulkowski
- Division of Pediatric Surgery, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
| | - Derek Wakeman
- Division of Pediatric Surgery, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
| | - Brian R Englum
- Division of Pediatric Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brian C Gulack
- Division of Pediatric Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | | | | | - Emily Christison-Lagay
- Division of Pediatric Surgery, Yale-New Haven Children's Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Sara A Mansfield
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | - Katie W Russell
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy- Kansas City, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Jun Tashiro
- Division of Pediatric Surgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, NY, USA
| | - Diana L Diesen
- Division of Pediatric Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Hanna Alemayehu
- Division of Pediatric Surgery, Emory University School of Medicine - Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Robert Ricca
- Division of Pediatric Surgery, University of South Carolina, Greenville, SC, USA
| | | | - Kristy L Rialon
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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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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Lee SH, Chung HW, Lee TY, Cheon YK. Effect of Rowachol on the Gallbladder Dysmotility Disorder Based on Gallbladder Ejection Fraction. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010105. [PMID: 36676729 PMCID: PMC9862614 DOI: 10.3390/medicina59010105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/30/2022] [Accepted: 12/31/2022] [Indexed: 01/05/2023]
Abstract
Background and Objectives: Although laparoscopic cholecystectomy is the preferred treatment method in patients who experience typical biliary pain with or without gallstones, medical treatment has not been extensively studied. Rowachol is a potent choleretic agent, comprising six cyclic monoterpenes. This study aimed to investigate the clinical improvement and changes in gallbladder ejection fraction (GBEF) by Rowachol treatment in patients with typical biliary pain. Materials and Methods: We retrospectively reviewed 138 patients with typical biliary pain who underwent cholescintigraphy from July 2016 to April 2022. We included patients who received Rowachol for more than 2 months and underwent follow-up GBEF measurements. Finally, we analyzed pre- and post-treatment symptoms and GBEF. GBEF was calculated using the fatty meal-stimulated cholescintigraphy. Results: This retrospective observational study included 31 patients; their median age was 46.0 (range, 26.0-72.7) years, and 22 (71.0%) were female. Overall, 9 (29.0%) patients had gallbladder stones or sludges (maximum size: 2 mm) on initial transabdominal ultrasonography. During a median follow-up of 23.3 months, the symptoms of 21 (67.7%) patients were resolved after a median Rowachol treatment of 10.0 months. The mean GBEF was significantly improved after Rowachol treatment (initial cholescintigraphy: 42.6% ± 16.2%; follow-up cholescintigraphy: 53.0% ± 18.1%, p = 0.012). In patients with a GBEF ≤35% (n = 9), Rowachol significantly increased the GBEF from 21.3% ± 8.3% to 49.1% ± 20.7% (p = 0.008). Conclusions: Rowachol may have beneficial medical effects that can improve gallbladder dysfunction and treatment response.
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Affiliation(s)
- Sang Hoon Lee
- Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Republic of Korea
| | - Hyun Woo Chung
- Department of Nuclear Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Republic of Korea
| | - Tae Yoon Lee
- Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Republic of Korea
| | - Young Koog Cheon
- Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Republic of Korea
- Correspondence: ; Tel.: +82-2-2030-7490
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Lazebnik LB, Golovanova EV, Volel BA, Korochanskaya NV, Lyalyukova EA, Mokshina MV, Mekhtiev SN, Mekhtieva OA, Metsaeva ZV, Petelin DS, Simanenkov VI, Sitkin SI, Cheremushkin SV, Chernogorova MV, Khavkin АI. Functional gastrointestinal disorders. Overlap syndrome Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine and Gastroenterological Scientific Society of Russia. EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2021:5-117. [DOI: 10.31146/1682-8658-ecg-192-8-5-117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Affiliation(s)
- L. B. Lazebnik
- Federal State Budgetary Educational Institution of Higher Education “A. I. Yevdokimov Moscow State University of Medicine and Dentistry” of the Ministry of Healthcare of the Russion Federation
| | - E. V. Golovanova
- Federal State Budgetary Educational Institution of Higher Education “A. I. Yevdokimov Moscow State University of Medicine and Dentistry” of the Ministry of Healthcare of the Russion Federation
| | - B. A. Volel
- I. M. Sechenov First Moscow Medical State University
| | - N. V. Korochanskaya
- Federal State Budgetary Educational Institution of Higher Education “Kuban State Medical University” Health Ministry of Russian Federation; State Budgetary Institution of Health Care “Region Clinic Hospital Nr 2” Health Ministry of Krasnodar Region
| | - E. A. Lyalyukova
- FSBEI VO “Omsk State Medical University” of the Ministry of Health
| | - M. V. Mokshina
- Institute of therapy a. instrumental diagnostics of FSBEI VO “Pacifi c State Medical Unuversity”
| | | | | | - Z. V. Metsaeva
- Republican clinical hospital of Health Care Ministry of Northen Ossetia- Alania Republic
| | - D. S. Petelin
- I. M. Sechenov First Moscow Medical State University
| | - V. I. Simanenkov
- North- Western state medical University named after I. I. Mechnikov, Ministry of health of the Russian Federation
| | - S. I. Sitkin
- North- Western state medical University named after I. I. Mechnikov, Ministry of health of the Russian Federation
| | - S. V. Cheremushkin
- Federal State Budgetary Educational Institution of Higher Education “A. I. Yevdokimov Moscow State University of Medicine and Dentistry” of the Ministry of Healthcare of the Russion Federation
| | - M. V. Chernogorova
- Moscow regional research and clinical Institute of M. F. Vladimirsky; GBUZ MO “Podolsk City Clinical Hospital No. 3”
| | - А. I. Khavkin
- FSBAI HPE “N. I. Pirogov Russian National Research Medical University” of the Ministry of Health of the Russian Federation
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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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Khan FA, Markwith N, Islam S. What is the role of the cholecystokinin stimulated HIDA scan in evaluating abdominal pain in children? J Pediatr Surg 2020; 55:2653-2656. [PMID: 32482410 DOI: 10.1016/j.jpedsurg.2020.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 01/22/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Cholecystokinin stimulated HIDA (CCK-HIDA) has been used to identify patients with biliary dyskinesia and select patients likely to benefit from cholecystectomy. The appropriate use of this study in children remains controversial and this study aims to better understand the utility of this test. METHODS Children who underwent a CCK-HIDA for evaluation of abdominal pain over a 15-year period were included, after excluding infants and patient's s/p liver transplant. Relevant clinical and outcomes data were abstracted and analyzed. RESULTS 124 patients met inclusion criteria. Mean age was 14.5 ± 2.6 years, Mean BMI was 27.9 ± 9.9 and 96 (77.4%) presented with right upper quadrant or epigastric pain. The mean ejection fraction (EF) was 58.5 ± 31.8%, with 37 (29.8%) < 35% EF. Using receiver operating curve analysis no specific EF threshold value predictive of resolution of symptoms was identified (AUC 0.510; p = 0.94). Using EF <35% and >35% and <20% and >20%, no association was noted with partial/complete resolution of symptoms. On multivariate regression analysis neither EF nor pain reproduction with CCK administration were independently associated with resolution of symptoms. CONCLUSIONS These data suggest that the CCK-HIDA scan is a poor predictor of benefit from cholecystectomy. Prospective large studies would help in identifying better criterion for patient selection, especially with the trend of increasing surgery for functional gallbladder disorders. TYPE OF STUDY Case cohort. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Faraz A Khan
- Division of Pediatric Surgery, Loma Linda University, Loma Linda, CA.
| | - Nicole Markwith
- Division of Pediatric Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Saleem Islam
- Division of Pediatric Surgery, University of Florida College of Medicine, Gainesville, FL.
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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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Nasri B, Glass T, Singh K, Saxe J. Biliary hyperkinesia: an indication for cholecystectomy? Surg Endosc 2020; 35:3244-3248. [PMID: 32632487 DOI: 10.1007/s00464-020-07757-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 06/23/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The main indications for laparoscopic cholecystectomy are stone-related diseases in adults. With a normal abdominal ultrasound (US), a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. Biliary dyskinesia or low gallbladder EF (EF < 35%) is a recognized indication for cholecystectomy. Recent articles report long-term resolution of symptoms in children with high EFs on the HIDA scan. The purpose of this study is to evaluate the response of patients with biliary colic and hyperkinetic gallbladder to cholecystectomy. We suggest that laparoscopic cholecystectomy might be a considerable surgical option in a subset of the adult population whose workup for food-related biliary abdominal pain is negative except for the high-value EF on HIDA scan. METHODS Data were consecutively collected from all patients who underwent laparoscopic cholecystectomy between June 2012 and June 2019 at a single institution. Cases were identified using Current Procedural Terminology codes. Patients older than 17 years of age with the negative US (no stone, no sludge, no gallbladder wall thickening) and EF greater than 80% on cholecystokinin (CCK)-HIDA scan were included in this study. All patients were seen at 2 weeks and 10-16 months after surgeries. RESULTS Over 7 years from June 2012 until June 2019, of 2116 patients who underwent laparoscopic cholecystectomy, 59 patients (2.78%) met study criteria. Postprandial abdominal pain was the most common symptom (43, 72.90%) followed by nausea/vomiting. Forty-seven patients (74.6%) had a reproduction of symptoms with CCK infusion. The average EF was 88.51%. Final pathology showed chronic cholecystitis in 41 (69.5%) patients, cholesterolosis in 13 (22%), polyp in 2 (3.4%). Thirty-six (61%) patients had complete resolution of symptoms, 9 (15%) patients had partial resolution, and 14 (24%) patients had no change. There was a complete resolution rate of 61% and an improvement rate of 76%. CONCLUSIONS In patients with biliary symptoms, negative ultrasound, and elevated EF on HIDA scan (EF > 80%), laparoscopic cholecystectomy led to a significant rate of symptomatic relief. Interestingly, 94% also had unexpected pathologic findings. This disease process requires further analysis, but this could represent a new indication for laparoscopic cholecystectomy in the adult population.
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Affiliation(s)
- Baongoc Nasri
- Department of Surgery, St Vincent Indianapolis, Indianapolis, IN, USA.
| | - Timothy Glass
- Department of Surgery, St Vincent Indianapolis, Indianapolis, IN, USA
| | - Kirpal Singh
- Department of Surgery, St Vincent Indianapolis, Indianapolis, IN, USA
| | - Jonathan Saxe
- Department of Surgery, St Vincent Indianapolis, Indianapolis, IN, USA
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Simon DA, Friesen CA, Schurman JV, Colombo JM. Biliary Dyskinesia in Children and Adolescents: A Mini Review. Front Pediatr 2020; 8:122. [PMID: 32266192 PMCID: PMC7105807 DOI: 10.3389/fped.2020.00122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/06/2020] [Indexed: 12/12/2022] Open
Abstract
Introduction: While functional gallbladder disorder is a well-recognized and defined condition in adults, its pediatric analog, biliary dyskinesia, lacks uniformity in diagnosis. Yet, biliary dyskinesia is among the most common conditions resulting in cholecystectomy in youth and its frequency continues to rise. The primary aims of the current review were assess the efficacy of cholecystectomy in children diagnosed with biliary dyskinesia and the utility of cholescintigraphy in predicting outcomes. Results: All previous studies assessing outcomes in youth with biliary dyskinesia have been retrospective and therefore of low quality. There is a lack of uniformity in patient selection. Short term follow-up reveals partial response in 63.4-100% with complete resolution in 44.2-100%. Only 4 studies have reported long-term outcomes with complete symptom resolution in 44-60.7%. The published research generally indicates that the gallbladder ejection fraction (GBEF) as determined by cholescintigraphy lacks utility in predicting cholecystectomy outcome utilizing the commonly used cut-off values. There are data suggesting that more extreme cut-off values may improve the predictive value of GBEF. Conclusion: There is a lack of consensus on the symptom profile defining biliary dyskinesia in youth and current literature does not support the use of cholescintigraphy to select patients for cholecystectomy. There is a substantial portion of pediatric patients diagnosed with biliary dyskinesia who do not experience long-term benefit from cholecystectomy. Well-designed prospective studies of surgical outcomes are lacking. Increasing the uniformity in patient selection, including both symptom profiles and cholescintigraphy results, will be key in understanding the utility of cholecystectomy for this condition.
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Affiliation(s)
- David A Simon
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, United States
| | - Craig A Friesen
- Division of Pediatric Gastroenterology, Children's Mercy Kansas City, Kansas City, MO, United States
| | - Jennifer V Schurman
- Division of Developmental and Behavioral Sciences, Children's Mercy Kansas City, Kansas City, MO, United States
| | - Jennifer M Colombo
- Division of Pediatric Gastroenterology, Children's Mercy Kansas City, Kansas City, MO, United States
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Li WG. Ultrasound Image Based Human Gallbladder 3D Modelling along with Volume and Stress Level Assessment. J Med Biol Eng 2019. [DOI: 10.1007/s40846-019-00493-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Abstract
Purpose
Three-dimensional (3D) gallbladder (GB) geometrical models are essential to GB motor function evaluation and GB wall biomechanical property identification by employing finite element analysis (FEA) in GB disease diagnosis with ultrasound systems. Methods for establishing such 3D geometrical models based on static two-dimensional (2D) ultrasound images scanned along the long-axis/sagittal and short-axis/transverse cross-sections in routine GB disease diagnosis at the beginning of emptying phase have not been documented in the literature so far.
Methods
Based on two custom MATLAB codes composed, two images were segmented manually to secure two sets of the scattered points for the long- and short-axis GB cross-section edges; and the points were best fitted with a piecewise cubic spline function, and the short-axis cross-section edges were lofted along the long-axis to yield a 3D geometrical model, then GB volume of the model was figured out. The model was read into SolidWorks for real surface generation and involved in ABAQUS for FEA.
Results
3D geometrical models of seven typical GB samples were established. Their GB volumes are with 15.5% and − 4.4% mean errors in comparison with those estimated with the ellipsoid model and sum-of-cylinders method but can be correlated to the latter very well. The maximum first principal in-plane stress in the 3D models is higher than in the ellipsoid model by a factor of 1.76.
Conclusions
A numerical method was put forward here to create 3D GB geometrical models and can be applied to GB disease diagnosis and GB shape analysis with principal component method potentially in the future.
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Bates JA, Dinnan K, Sharp V. Biliary hyperkinesia, a new diagnosis or misunderstood pathophysiology of dyskinesia: A case report. Int J Surg Case Rep 2019; 55:80-83. [PMID: 30716707 PMCID: PMC6360460 DOI: 10.1016/j.ijscr.2019.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/02/2019] [Accepted: 01/15/2019] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Biliary colic, characterized by intermittent right upper quadrant abdominal pain is a common complaint in the United States population. Patients whose pain is undiagnosed by ultrasound generally undergo hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (HIDA-CCK) to assess function of the gallbladder and biliary tree. Traditionally, two outcomes are possible based on a measured ejection fraction of the gallbladder: either dyskinesia or normal function is diagnosed. Biliary dyskinesia, or hypokinesia of the gallbladder, is accepted as an ejection fraction less than 35%, while an accepted normal functioning gallbladder ejection fraction is greater than 35%. CASE We report a case of a fifteen-year-old female who had functional gallbladder disease per Rome IV criteria due to intermittent biliary colic, with exception to the ejection fraction measurement which was elevated at 96.5%. She underwent laparoscopic cholecystectomy with complete symptom resolution. DISCUSSION As demonstrated in the literature reviewed here, these subsets of patients, who present with normal to high ejection fractions, have undergone laparoscopic cholecystectomy with resolution of pain in several case studies. CONCLUSION Many unknown variables still exist due to lack of prospective studies, most notably the pathophysiology and definitive indications for surgical treatment. As such, we propose that surgical options should not be limited to those who display the traditional findings of biliary dyskinesia, but also patients who demonstrate typical symptoms with normal to elevated ejection fraction, following work up to rule out the extensive differential diagnoses for right upper quadrant abdominal pain.
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Affiliation(s)
- John A Bates
- Beaumont Health Farmington Hills, General Surgery Department, 28050 Grand River Avenue, Farmington Hills, MI 48336, USA.
| | - Kelly Dinnan
- Beaumont Health Farmington Hills, General Surgery Department, 28050 Grand River Avenue, Farmington Hills, MI 48336, USA.
| | - Victoria Sharp
- Beaumont Health Farmington Hills, General Surgery Department, 28050 Grand River Avenue, Farmington Hills, MI 48336, USA.
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Tsai TJ, Chan HH, Lai KH, Shih CA, Kao SS, Sun WC, Wang EM, Tsai WL, Lin KH, Yu HC, Chen WC, Wang HM, Tsay FW, Lin HS, Cheng JS, Hsu PI. Gallbladder function predicts subsequent biliary complications in patients with common bile duct stones after endoscopic treatment? BMC Gastroenterol 2018; 18:32. [PMID: 29486713 PMCID: PMC6389262 DOI: 10.1186/s12876-018-0762-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 02/22/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In patients with common bile duct stones (CBDS) and intact gallbladder, further management for the gallbladder after the CBDS clearance is still controversial. The relationship between gallbladder motility and the biliary complications were seldom discussed. Our study is to predict the subsequent biliary complications by gallbladder function test using fatty meal sonography (FMS) in patients with CBDS who had been treated by endoscopic retrograde cholangiopancreatography (ERCP). METHODS Patients with an intact gallbladder and CBDS after endoscopic clearance of bile duct were enrolled. Patients received a fatty meal sonography after liver function returned to normal. The fasting volume, residual volume, and gallbladder ejection fraction (GBEF) in FMS were measured. Relationships of patients' characteristics, gallbladder function and recurrent biliary complication were analyzed. RESULTS From 2011 to 2014, 118 patients were enrolled; 86 patients had calculus gallbladders, and 32 patients had acalculous gallbladders. After a mean follow- up of 33 months, 23 patients had recurrent biliary complications. Among 86 patients with calculus gallbladder, 15 patients had spontaneous clearance of gallbladder stones; 14 patients received cholecystectomy due to acute cholecystitis or recurrent colic pain with smooth postoperative courses. In the follow up period, six patients died of non-biliary causes. The GBEF is significant reduced in most patients with a calculus gallbladder in spite of stone color. Calculus gallbladder, alcohol drinking and more than one sessions of initial endoscopic treatment were found to be the risk factors of recurrent biliary complication. CONCLUSIONS Gallbladder motility function was poorer in patients with a calculus gallbladder, but it cannot predict the recurrent biliary complication. Since spontaneous clearance of gallbladder stone may occur, wait and see policy of gallbladder management after endoscopic treatment of CBDS is appropriate, but regular follow- up in those patients with risk factors for recurrence is necessary.
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Affiliation(s)
- Tzung-Jiun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Hoi-Hung Chan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China. .,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China. .,Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan, Republic of China. .,Department of Business Management, National Sun Yat-sen University, Kaohsiung, Taiwan, Republic of China. .,College of Pharmacy and Health Care, Tajen University, Pingtung city, Taiwan, Republic of China.
| | - Kwok-Hung Lai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Chih-An Shih
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Sung-Shuo Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Wei-Chih Sun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - E-Ming Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Wei-Lun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Kung-Hung Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Hsien-Chung Yu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Wen-Chi Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Huay-Min Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Feng-Woei Tsay
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Huey-Shyan Lin
- Department of Health-Business Administration, Fooyin University, Kaohsiung, Taiwan, Republic of China
| | - Jin-Shiung Cheng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Ping-I Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
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Lim JU, Joo KR, Won KY, Lim SJ, Joo SH, Yang YJ. Predictor of abnormal gallbladder ejection fraction in patients with atypical biliary pain: Histopathological point of view. Medicine (Baltimore) 2017; 96:e9269. [PMID: 29390484 PMCID: PMC5758186 DOI: 10.1097/md.0000000000009269] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Jun Uk Lim
- Department of Gastroenterology, Sejong General Hospital, Bucheon
| | | | | | | | | | - You-Jung Yang
- Department of Nuclear Medicine, Kyung Hee University Hospital at Gang Dong, Kyung Hee University School of Medicine, Seoul, Republic of Korea
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15
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Abstract
Cholecystectomy rates for biliary dyskinesia in children are rising in the United States, but not in other countries. Biliary dyskinesia is a validated functional gallbladder disorder in adults, requiring biliary colic in the diagnosis. In contrast, most studies in children require upper abdominal pain, absent gallstones on ultrasound, and an abnormal gallbladder ejection fraction (GBEF) on cholecystokinin-stimulated cholescintigraphy for diagnosis. We aimed to systematically review existing literature in biliary dyskinesia in children, determine the validity and reliability of diagnostic criteria, GBEF, and to assess outcomes following cholecystectomy. We performed a systematic review following the PRISMA checklist and searched 7 databases including PubMed, Scopus, Embase, Ovid, MEDLINE, ProQuest, Web of Science, and the Cochrane library. Bibliographies of articles were screened for additional studies. Our search terms yielded 916 articles of which 28 were included. Three articles were manually added from searched references. We reviewed 31 peer-reviewed publications, all retrospective chart reviews. There was heterogeneity in diagnostic criteria and GBEF values. Outcomes after laparoscopic cholecystectomy varied from 34% to 100% success, and there was no consensus concerning factors influencing outcomes. The observational, retrospective study designs that comprised our review limited interpretation of safety and efficacy of the investigations and treatment in biliary dyskinesia in children. Symptoms of biliary dyskinesia overlapped with functional dyspepsia. There is a need for consensus on symptoms defining biliary dyskinesia, validation of testing required for diagnosis of biliary dyskinesia, and randomized controlled trials comparing medical versus surgical management in children with upper abdominal pain.
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16
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Hyun JJ, Lee HS, Kim CD, Dong SH, Lee SO, Ryu JK, Lee DH, Jeong S, Kim TN, Lee J, Koh DH, Park ET, Lee IS, Yoo BM, Kim JH. Efficacy of Magnesium Trihydrate of Ursodeoxycholic Acid and Chenodeoxycholic Acid for Gallstone Dissolution: A Prospective Multicenter Trial. Gut Liver 2016; 9:547-55. [PMID: 26087862 PMCID: PMC4478000 DOI: 10.5009/gnl15015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background/Aims Cholecystectomy is necessary for the treatment of symptomatic or complicated gallbladder (GB) stones, but oral litholysis with bile acids is an attractive alternative therapeutic option for asymptomatic or mildly symptomatic patients. This study was conducted to evaluate the efficacy of magnesium trihydrate of ursodeoxycholic acid (UDCA) and chenodeoxycholic acid (CDCA) on gallstone dissolution and to investigate improvements in gallstone-related symptoms. Methods A prospective, multicenter, phase 4 clinical study to determine the efficacy of orally administered magnesium trihydrate of UDCA and CDCA was performed from January 2011 to June 2013. The inclusion criteria were GB stone diameter ≤15 mm, GB ejection fraction ≥50%, radiolucency on plain X-ray, and asymptomatic/mildly symptomatic patients. The patients were prescribed one capsule of magnesium trihydrate of UDCA and CDCA at breakfast and two capsules at bedtime for 6 months. The dissolution rate, response rate, and change in symptom score were evaluated. Results A total of 237 subjects were enrolled, and 195 subjects completed the treatment. The dissolution rate was 45.1% and the response rate was 47.2% (92/195) after 6 months of administration of magnesium trihydrate of UDCA and CDCA. Only the stone diameter was significantly associated with the response rate. Both the symptom score and the number of patients with symptoms significantly decreased regardless of stone dissolution. Adverse events necessitating discontinuation of the drug, surgery, or endoscopic management occurred in 2.5% (6/237) of patients. Conclusions Magnesium trihydrate of UDCA and CDCA is a well-tolerated bile acid that showed similar efficacy for gallstone dissolution and improvement of gallstone-related symptoms as that shown in previous studies.
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Affiliation(s)
- Jong Jin Hyun
- Department of Internal Medicine, Korea University College of Medicine, Korea
| | - Hong Sik Lee
- Department of Internal Medicine, Korea University College of Medicine, Korea
| | - Chang Duck Kim
- Department of Internal Medicine, Korea University College of Medicine, Korea
| | - Seok Ho Dong
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung-Ok Lee
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Ji Kon Ryu
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Don Haeng Lee
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Tae Nyeun Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jin Lee
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Dong Hee Koh
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Eun Taek Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - In-Seok Lee
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Byung Moo Yoo
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Jin Hong Kim
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
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17
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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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18
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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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19
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Ahn KS, Han HS, Cho JY, Yoon YS, Kim C, Lee WW. Long-term follow-up of non-operated patients with symptomatic gallbladder stones: a retrospective study evaluating the role of Hepatobiliary scanning. BMC Gastroenterol 2015; 15:136. [PMID: 26472428 PMCID: PMC4608107 DOI: 10.1186/s12876-015-0368-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 10/06/2015] [Indexed: 01/06/2023] Open
Abstract
Background To assess hepatobiliary (HB) scans for predicting recurrent symptoms in nonoperated patients with mild or vague symptomatic gallstones. Methods Data of 170 patients with symptomatic gallstone and who had not undergone cholecystectomy were retrospectively enrolled. These patients were divided into two groups according to whether or not operations were performed due to recurrent symptoms during the follow-up period. The demographic factors and gallbladder ejection fraction (GBEF) of HB scans were compared between the groups. Additionally, symptom-free rate was obtained beginning from the date of the HB scan to the date of surgery, and analyzed based on the level of GBEF. Results Among the 170 enrolled patients, two patients who underwent cholecystectomy for other disease were excluded. Thirty-four patients underwent cholecystectomy due to recurrent symptoms (OP group), and the remaining 136 patients did not experience recurrent symptoms and therefore did not undergo cholecystectomy (non-OP group). In the OP group, the mean GBEF was significantly lower than that of the non-OP group (28.8 ± 29.9 vs. 66.3 ± 20.0; P < 0.001). The rate of lower GBEF (<30 %, including non-visualization of the gallbladder) was significantly higher in the OP group than the non-OP group (54.9 vs. 5.1 %; P < 0.001). In patients with non-visualization of the gallbladder or GBEF <30 %, the 10-year symptom-free rate was significantly lower than those with a GBEF ≥ 30 % (19.8 % vs. 81.9 %; P < 0.001). Conclusion HB scanning is a useful objective modality to differentiate gallstone-related symptoms from other etiologies and predict recurrent symptoms.
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Affiliation(s)
- Keun Soo Ahn
- Department of Surgery, Keimyung University Dongsan Medical Center, 56 Chungho-ro, Jung-gu, Daegu city,, 41931, Korea.
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Korea, 300 Gumi-dong, Bundagn-gu, Seongnam city, Gyeonggido, 463-707, Korea.
| | - Jai Young Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Korea, 300 Gumi-dong, Bundagn-gu, Seongnam city, Gyeonggido, 463-707, Korea.
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Korea, 300 Gumi-dong, Bundagn-gu, Seongnam city, Gyeonggido, 463-707, Korea.
| | - Chulhan Kim
- Department of Nuclear Medicine, Korea University Ansan Hospital, Ansan city, Gyeonggido,, 425-707, Korea.
| | - Won Woo Lee
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Korea, Gyeonggido, 463-707, Korea.
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Eckenrode AH, Ewing JA, Kotrady J, Hale AL, Smith DE. HIDA Scan with Ejection Fraction is over Utilized in the Management of Biliary Dyskinesia. Am Surg 2015. [DOI: 10.1177/000313481508100714] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients with upper abdominal pain, nausea, and vomiting are often evaluated with ultrasound to diagnose symptomatic cholelithiasis or cholecystitis. With a normal ultrasound, a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. The purpose of this study was to evaluate whether the HIDA scan with EF was appropriately utilized in considering cholecystectomy. Over 18 months, we performed 1533 HIDA scans with EF. After exclusion, 1501 were analyzable, 438 of whom underwent laparoscopic cholecystectomy. Patients were divided into two groups: those with typical and atypical symptoms of biliary colic. Our primary endpoint was symptom resolution of those who underwent laparoscopic cholecystectomy. Symptom resolution was assessed by chart review of postop visits or readmissions. In patients with typical symptoms, resolution occurred in 66 per cent of patients with positive HIDA and 77 per cent with negative HIDA ( P = 0.292). In patients with atypical symptoms, resolution occurred in 64 per cent of patients with positive HIDA and 43 per cent with negative HIDA ( P = 0.013). A HIDA scan with EF was not useful in patients with typical symptoms of biliary colic and negative ultrasounds, and should not be used to make a decision for cholecystectomy. However, this test can be helpful in patients with atypical symptoms, as it does predict symptom improvement in this group.
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Affiliation(s)
| | | | | | | | - Dane E. Smith
- Greenville Health System, Greenville, South Carolina
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21
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Agresta F, Campanile FC, Vettoretto N, Silecchia G, Bergamini C, Maida P, Lombari P, Narilli P, Marchi D, Carrara A, Esposito MG, Fiume S, Miranda G, Barlera S, Davoli M. Laparoscopic cholecystectomy: consensus conference-based guidelines. Langenbecks Arch Surg 2015; 400:429-53. [PMID: 25850631 DOI: 10.1007/s00423-015-1300-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/24/2015] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery. METHODS In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.
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Affiliation(s)
- Ferdinando Agresta
- Department of Surgery, Presidio Ospedaliero di Adria (RO), Adria, RO, Italy,
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22
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Edwards MA, Mullenbach B, Chamberlain SM. Pain provocation and low gallbladder ejection fraction with CCK cholescintigraphy are not predictive of chronic acalculous gallbladder disease symptom relief after cholecystectomy. Dig Dis Sci 2014; 59:2773-8. [PMID: 24852884 DOI: 10.1007/s10620-014-3213-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 05/12/2014] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Chronic acalculous gallbladder disease (CAGD) falls within the spectrum of diseases associated with gallbladder dysmotility. Cholecystokinin-cholescintigraphy (CCK-CS) has been used to evaluate for CAGD, with a gallbladder ejection fraction (GBEF) of <35 % being indicative of gallbladder dysfunction. The reproduction of biliary colic upon administration of CCK has been cited as indicative of CAGD. Our purpose was to determine whether low GBEF or reproduction of pain during CCK-CS was predictor of surgical outcomes related to resolution of symptoms or as a correlate to gallbladder pathology. METHODS A retrospective review of patients was performed to evaluate adults with a diagnosis of CAGD who underwent CCK-CS prior to surgical intervention. CPT and ICD-9 coding queries were used to identify the patient population. Patients with cholelithiasis were excluded. RESULTS Sixty-four patients met inclusion criteria. Two patients were lost to follow-up and were excluded. During CCK-CS, 41 patients (66 %) reported symptoms similar to their presenting complaint. Twenty-one patients reported no symptoms with CCK-CS. There was no significant relationship between gallbladder pathology and either GBEF or reproduction of symptoms with CCK-CS (p = 0.14). About 81 % of patients (n = 50) had relief of symptoms following cholecystectomy. Sixty-six percentage of patients (n = 33) with long-term symptom relief after cholecystectomy had reproduction of symptoms with CCK-CS. Nineteen percentage of all patients (n = 12) had long-term symptom recurrence despite surgery. Eight of these patients (66 %) had symptom reproduction with CCK-CS. There was no significant correlation with either the GBEF or symptoms reproduction with CCK-CS as a predictor of postoperative outcome (p = 0.12). CONCLUSION Provocation of pain by CCK-CS and low GBEF are unreliable predictors of postoperative relief of symptoms following cholecystectomy for biliary dyskinesia or chronic acalculous gallbladder disease.
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Affiliation(s)
- Michael A Edwards
- General and Minimally Invasive Surgery Division, Department of Surgery, Temple University School of Medicine, Philadelphia, PA, USA
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23
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Prospective Assessment of Dynamic CT and MR Cholangiography in Functional Biliary Pain. AJR Am J Roentgenol 2013; 201:W271-82. [DOI: 10.2214/ajr.12.9538] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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24
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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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25
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Ziessman HA. Sincalide cholescintigraphy--32 years later: evidence-based data on its clinical utility and infusion methodology. Semin Nucl Med 2012; 42:79-83. [PMID: 22293163 DOI: 10.1053/j.semnuclmed.2011.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Harvey A Ziessman
- Department of Radiology and Radiological Sciences, Division of Nuclear Medicine, Johns Hopkins University, Baltimore, MD 21287, USA.
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DuCoin C, Faber R, Ilagan M, Ruderman W, Wier D. Normokinetic biliary dyskinesia: a novel diagnosis. Surg Endosc 2012; 26:3088-93. [PMID: 22648109 DOI: 10.1007/s00464-012-2342-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 04/24/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Biliary dyskinesia diagnosed with CCK-HIDA scan and ejection fraction less than 35 % has been successfully treated by laparoscopic cholecystectomy. However, a population of patients with symptomatic biliary pain and a normal CCK-HIDA scan never receive a diagnosis, and thus no definitive treatment. Some of these patients report a reproducible pain during their CCK-HIDA scan. It is hypothesized that these patients have a novel diagnosis, normokinetic biliary dyskinesia, and may have resolution of pain when treated with cholecystectomy. METHODS A retrospective chart review was completed looking for patients with biliary pain in accordance with the ROME III criteria. Additional inclusion criteria were (1) greater than age 18 years, (2) reproducible biliary symptoms during the CCK-HIDA scan, and (3) an ejection fraction greater than 35 %. Treatment modality was laparoscopic cholecystectomy. Descriptive statistics were preformed, and data were reported as mean ± standard deviation and range. RESULTS Nineteen patients met the inclusion criteria for this study from August 2008 to July 2011. There were 15 women and 4 men with a mean age of 48.4 ± 13.0 years. The mean ejection fraction was 75.1 ± 19.4 %. The average duration of preoperative symptoms was 6.8 ± 5.9 months and postoperative follow-up was 21.8 ± 10.6 months. Seventeen patients had complete resolution of symptoms, one had partial resolution, and one had no change. There was a complete resolution rate of 89.5 % and an improvement rate of 94.7 %. CONCLUSIONS We suggest that patients who present with biliary pain, a normal CCK-HIDA scan with an ejection fraction greater than 35 %, and with reproducible symptoms on infusion of CCK could have a novel diagnosis: normokinetic biliary dyskinesia. Currently, these patients are excluded from the diagnosis of biliary dyskinesia and thus treatment. We hypothesize a potential new diagnosis, suggest cholecystectomy as treatment, and recommend a prospective study design for further evaluation.
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Affiliation(s)
- Christopher DuCoin
- Department of Surgery and Center for Digestive & Metabolic Surgery, Orlando Health, 77 West Underwood Street, Orlando, FL 32806, USA.
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Cholecystokinin-cholescintigraphy in adults: consensus recommendations of an interdisciplinary panel. Clin Nucl Med 2012; 37:63-70. [PMID: 22157031 DOI: 10.1097/rlu.0b013e31823e26bb] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Skalicky M. Dynamic changes of echogenicity and the size of the papilla of Vater before and after cholecystectomy. J Int Med Res 2011; 39:1051-62. [PMID: 21819739 DOI: 10.1177/147323001103900340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This study investigated the changes in echogenicity, as measured by endoscopic ultrasound, and the surface area of the papilla of Vater (PV) and their relationship with postoperative symptoms in a group of 80 patients with symptomatic gallstones before and at 3 and 6 months after cholecystectomy. After cholecystectomy, 50 patients experienced early atypical symptoms characteristic of postcholecystectomy syndrome (PCS) and 30 patients were asymptomatic. The surface area of the PV was larger than normal prior to surgery and increased after surgery. The healthy PV is isoechogenic, but 48% of all patients were anisoechogenic preoperatively, increasing to 61% at 3 months after surgery, and decreasing to 25% at 6 months postsurgery. There was no significant difference between the two patient groups, suggesting that the changes observed in the PV do not explain the presence of the atypical symptoms of PCS.
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Affiliation(s)
- M Skalicky
- Division of Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia.
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Irshad A, Ackerman SJ, Spicer K, Baker N, Campbell A, Anis M, Shazly M. Ultrasound Evaluation of Gallbladder Dyskinesia: Comparison of Scintigraphy and Dynamic 3D and 4D Ultrasound Techniques. AJR Am J Roentgenol 2011; 197:1103-1110. [DOI: 10.2214/ajr.10.5391] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Abid Irshad
- Department of Radiology, Medical University of South Carolina, 169 Ashley Ave, Charleston, SC 29425
| | - Susan J. Ackerman
- Department of Radiology, Medical University of South Carolina, 169 Ashley Ave, Charleston, SC 29425
| | - Kenneth Spicer
- Department of Radiology, Medical University of South Carolina, 169 Ashley Ave, Charleston, SC 29425
| | - Nathanial Baker
- Department of Biostatistics and Epidemiology, Medical University of South Carolina, Charleston SC
| | - Amy Campbell
- Department of Radiology, Medical University of South Carolina, 169 Ashley Ave, Charleston, SC 29425
| | - Munazza Anis
- Department of Radiology, Medical University of South Carolina, 169 Ashley Ave, Charleston, SC 29425
| | - Mehwish Shazly
- Department of Radiology, Medical University of South Carolina, 169 Ashley Ave, Charleston, SC 29425
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Abstract
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.
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Cholecystokinin-cholescintigraphy in adults: consensus recommendations of an interdisciplinary panel. Clin Gastroenterol Hepatol 2011; 9:376-84. [PMID: 21334459 DOI: 10.1016/j.cgh.2011.02.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Revised: 02/08/2011] [Accepted: 02/10/2011] [Indexed: 02/07/2023]
Abstract
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.
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Morris-Stiff G, Falk G, Kraynak L, Rosenblatt S. The cholecystokin provocation HIDA test: recreation of symptoms is superior to ejection fraction in predicting medium-term outcomes. J Gastrointest Surg 2011; 15:345-9. [PMID: 20824367 DOI: 10.1007/s11605-010-1342-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 08/18/2010] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Gareth Morris-Stiff
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Abstract
Functional gallbladder disorder, commonly referred to as gallbladder dyskinesia, is characterized by the occurrence of abdominal pain resembling gallbladder pain but in the absence of gallstones. The diagnosis and management of this condition can be confusing even for the most astute clinician. The aim of this article is to clarify the identification and management of patients with suspected functional gallbladder disorder.
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Ziessman HA, Tulchinsky M, Maurer AH. Reply: Sincalide-Stimulated Cholescintigraphy: What Is the Standard? J Nucl Med 2010. [DOI: 10.2967/jnumed.110.076646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ziessman HA. Nuclear medicine hepatobiliary imaging. Clin Gastroenterol Hepatol 2010; 8:111-6. [PMID: 19879969 DOI: 10.1016/j.cgh.2009.10.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 10/09/2009] [Accepted: 10/10/2009] [Indexed: 02/07/2023]
Abstract
Nuclear medicine hepatobilary imaging (HIDA) is a time proven imaging methodology that uses radioactive drugs and specialized cameras to make imaging diagnoses based on physiology. HIDA radiopharmaceuticals are extracted by hepatocytes in the liver and cleared through the biliary system similar to bilirubin. The most common indication for HIDA imaging is acute cholecystitis, diagnosed by nonfilling of the gallbladder due to cystic duct obstruction. HIDA can detect high grade biliary obstruction prior to ductal dilatation; images reveal a persistent hepatogram without biliary clearance due to the high backpressure. HIDA also aids in the diagnosis of partial biliary obstruction due to stones, biliary stricture, and sphincter of Oddi obstruction. It can confirm biliary leakage postcholecystectomy and hepatic transplantation. Calculation of a gallbladder ejection fraction after cholecystokinin infusion is commonly used to diagnose chronic acalculous gallbladder disease. Diseased gallbladders do not contract. There are many other less common but valuable diagnostic indications for HIDA imaging.
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Affiliation(s)
- Harvey A Ziessman
- Division of Nuclear Medicine, Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
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36
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Ziessman HA, Tulchinsky M, Lavely WC, Gaughan JP, Allen TW, Maru A, Parkman HP, Maurer AH. Sincalide-Stimulated Cholescintigraphy: A Multicenter Investigation to Determine Optimal Infusion Methodology and Gallbladder Ejection Fraction Normal Values. J Nucl Med 2010; 51:277-81. [DOI: 10.2967/jnumed.109.069393] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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37
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Dibaise JK. Evaluation and management of functional biliary pain in patients with an intact gallbladder. Expert Rev Gastroenterol Hepatol 2009; 3:305-13. [PMID: 19485811 DOI: 10.1586/egh.09.17] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- John K Dibaise
- Professor of Medicine, Division of Gastroenterology and Hepatology, Scottsdale, AZ 85259, USA.
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38
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Abstract
Function tests in gastroenterology and hepatology aim to provide criteria for diagnosis of specific disorders and for prediction of patient responses to therapy. This review focuses on the utility of function tests in the management of gallstone disease and functional biliary disorders. In gallstone disease, function tests may be considered in the selection of candidates for nonsurgical therapy of gallbladder stones only. In cases of suspected functional biliary disorders, experts have advocated the use of classical noninvasive tests such as hepatobiliary scintigraphy. However, unequivocal evidence for their utility in diagnosis or patient selection for invasive treatment is yet to be provided. Recently, more advanced noninvasive tests such as real-time ultrasonography or secretin-stimulated magnetic resonance cholangiopancreaticography have been described. Controlled trials using these novel techniques may provide a rationale for the use of function tests in clinical management of calculous and acalculous biliary diseases, but are currently not available.
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Affiliation(s)
- Marc Dauer
- Department of Medicine II, Saarland University Hospital, Saarland University, Kirrberger Str., 66421 Homburg/Saar, Germany.
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39
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Ziessman HA. Interventions Used With Cholescintigraphy for the Diagnosis of Hepatobiliary Disease. Semin Nucl Med 2009; 39:174-85. [DOI: 10.1053/j.semnuclmed.2008.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Abstract
Functional disorders of the biliary tract include gallbladder dyskinesia (GBD) and sphincter of Oddi dysfunction (SOD). The diagnosis of GBD is made if the gallbladder ejection fraction is less than 35% to 40% using cholecystokinin cholescintigraphy. Despite slightly inferior outcomes compared with calculous disease, patients who have GBD should be treated with cholecystectomy. SOD is most often noted in the postcholecystectomy patient and symptoms can be biliary or pancreatic in nature. The gold standard for diagnosis remains manometry, with basal biliary or pancreatic sphincter pressures measuring greater than 40 mm Hg. Patients who have increased pressures may benefit from endoscopic sphincterotomy.
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Affiliation(s)
- Melina C Vassiliou
- Department of General Surgery, Division of Minimally Invasive Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
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Role of Quantitative Cholescintigraphy for Planning Laparoscopic Cholecystectomy in Patients With Gallbladder Dyskinesia and Chronic Abdominal Pain. Surg Laparosc Endosc Percutan Tech 2009; 19:16-9. [DOI: 10.1097/sle.0b013e31818eb2e5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Cross-sectional imaging of acute and chronic gallbladder inflammatory disease. AJR Am J Roentgenol 2009; 192:188-96. [PMID: 19098200 DOI: 10.2214/ajr.07.3803] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The purpose of this article is to provide a comprehensive review of the clinical and cross-sectional imaging features of a variety of acute and chronic gallbladder inflammatory diseases. CONCLUSION Inflammatory gallbladder diseases are a common source of abdominal pain and cause considerable morbidity and mortality. Although acute uncomplicated cholecystitis and chronic cholecystitis are frequently encountered, numerous other gallbladder inflammatory conditions may also occur that can be readily diagnosed by cross-sectional imaging.
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Abstract
BACKGROUND The optimal treatment for patients with suspected biliary dyskinesia is controversial. Some studies found that cholecystectomy produced symptomatic improvement in patients with gallbladder dyskinesia (diagnosed by low gallbladder ejection fraction) while others found no significant benefit. Some studies have shown that gallbladder ejection fraction can discriminate patients who would benefit from cholecystectomy. Other studies have not confirmed this. OBJECTIVES The aim of this review was to compare the benefits and harms of cholecystectomy for patients with suspected gallbladder dyskinesia. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2008. SELECTION CRITERIA We considered for inclusion all randomised clinical trials comparing cholecystectomy versus no cholecystectomy on patients with gallbladder dyskinesia. DATA COLLECTION AND ANALYSIS We collected the data on the characteristics, methodological quality, mortality, number of patients in whom symptoms were improved or cured from the one identified trial. We planned to analyse the data using the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we planned to calculate the risk ratio (RR) with 95% confidence intervals based on intention-to-treat analysis. MAIN RESULTS We included one trial with 21 patients randomised: 11 to cholecystectomy and 10 to control (no cholecystectomy). This trial was considered to be of high risk of bias as patients were not blinded and the procedure-related morbidity was not reported. There was no mortality in either group. All patients in the cholecystectomy group and only one patient in the control group had improvement in symptoms (P = 0.0001) after a mean follow-up period of 33.6 months. AUTHORS' CONCLUSIONS The evidence for the benefits and harms of cholecystectomy in gallbladder dyskinesia from randomised clinical trials is based on a single small trial at risk of bias. Further randomised clinical trials with improved bias control are necessary to confirm or reject the promising results.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
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Abstract
The term biliary dyskinesia commonly describes a motility disorder of the biliary tract that is divided into two main categories: gallbladder dyskinesia (GBD) and sphincter of Oddi dysfunction (SOD). SOD is further subdivided into biliary SOD and pancreatic SOD. GBD causes typical biliary colic without gallstones, whereas SOD typically presents with recurrent pancreatitis or chronic abdominal pain, usually after cholecystectomy. GBD and SOD are uncommon in children. Based on adult experience, this review discusses the diagnosis and treatment of GBD and SOD in the pediatric population.
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Affiliation(s)
- Michael S Halata
- Department of Pediatric Gastroenterology, Maria Fareri Children's Hospital, New York Medical College, Munger Pavilion, Room 101, Valhalla, NY 10595, USA.
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45
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Young SB, Arregui M, Singh K. HIDA scan ejection fraction does not predict sphincter of Oddi hypertension or clinical outcome in patients with suspected chronic acalculous cholecystitis. Surg Endosc 2008; 20:1872-8. [PMID: 17031746 DOI: 10.1007/s00464-005-0245-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Accepted: 10/25/2005] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- S B Young
- St. Vincent Hospital, 8402 Harcourt Road, Suite 815, Indianapolis, IN 46260, USA
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46
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Cofer JB, Dart B. Reproduction of Postprandial Symptoms with Cholecystokinin Injection: An Indication for Cholecystectomy without the Presence of Gallstones or an Abnormal Ejection Fraction on Quantitative Cholescintigraphy? Am Surg 2007. [DOI: 10.1177/000313480707300710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Quantitative cholescintigraphy with cholecystokinin injection is commonly used to assess patients without evidence of cholelithiasis but with functional biliary pain. However, normal results may not always exclude the possibility of pathologic biliary disease. Retrospective review of prospectively collected data on eight patients with biliary colic, no evidence of cholelithiasis, a normal quantitative cholescintigraphy ejection fraction but with reproduction of their specific symptoms on cholecystokinin injection was performed. The mean ejection fraction was 66.2 per cent. All of these patients underwent cholecystectomy with complete resolution of their symptoms. Pathology was abnormal in all cases. Patients with symptoms suggestive of biliary disease with reproduction of these symptoms on cholecystokinin injection may benefit from cholecystectomy even in the absence of abnormally low ejection fraction on quantitative cholescintigraphy.
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Affiliation(s)
- Joseph B. Cofer
- Department of Surgery, University of Tennessee College of Medicine–Chattanooga, Chattanooga, Tennessee
| | - B.W. Dart
- Department of Surgery, University of Tennessee College of Medicine–Chattanooga, Chattanooga, Tennessee
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47
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Ziessman HA. Functional hepatobiliary disease: chronic acalculous gallbladder and chronic acalculous biliary disease. Semin Nucl Med 2006; 36:119-32. [PMID: 16517234 DOI: 10.1053/j.semnuclmed.2005.12.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Harvey A Ziessman
- Division of Nuclear Medicine, The Russell H. Morgan Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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Rau B, Friesen CA, Daniel JF, Qadeer A, You-Li D, Roberts CC, Holcomb GW. Gallbladder wall inflammatory cells in pediatric patients with biliary dyskinesia and cholelithiasis: a pilot study. J Pediatr Surg 2006; 41:1545-8. [PMID: 16952589 DOI: 10.1016/j.jpedsurg.2006.05.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND/PURPOSE Inflammation has been implicated in functional gastrointestinal disorders, including functional dyspepsia and irritable bowel syndrome. This study was undertaken to evaluate gallbladder wall inflammatory cells in children with abdominal pain related to gallstones and biliary dyskinesia to determine the candidate cell types that may be contributing to the pathophysiology of these entities. METHODS Gallbladder specimens from 20 patients with cholelithiasis, 20 biliary patients with dyskinesia, and 12 autopsy controls were evaluated in a blinded fashion. Eosinophil, tryptase-positive, and CD3+ cell densities were determined for the lamina propria and muscularis mucosa layers and compared between groups. RESULTS Patients with biliary dyskinesia and cholelithiasis had a 9- to 12-fold increase in mean and peak mast cell densities, respectively, in both layers as compared with controls. Peak (13.7 vs 8.4) and mean (9.2 vs 5.2) CD3+ cell densities were increased in the muscularis mucosae of cholelithiasis specimens as compared with biliary dyskinesia specimens. CONCLUSION Gallbladder wall inflammatory cell densities, particularly mast cells, differ between children with cholelithiasis, children with biliary dyskinesia, and controls. Future studies are warranted to define the roles for specific inflammatory cell types.
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Affiliation(s)
- Brian Rau
- University of Missouri-Kansas City, Kansas City, MO, USA
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Cahan MA, Balduf L, Colton K, Palacioz B, McCartney W, Farrell TM. Proton pump inhibitors reduce gallbladder function. Surg Endosc 2006; 20:1364-7. [PMID: 16858534 DOI: 10.1007/s00464-005-0247-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Accepted: 02/23/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the authors' previous study of gallbladder function before and after fundoplication, 58% of the patients demonstrated preoperative gallbladder motor dysfunction, and 86% of those retested after operation and cessation of proton pump inhibitors (PPIs) normalized. Because no study has directly assessed the impact of antisecretory agents on gallbladder function, this study measured gallbladder ejection fraction (GBEF) in healthy volunteers before and after initiation of PPIs. METHODS A total of 19 subjects completed the study, which included baseline determination of GBEF by cholecystokinin-stimulated hepatobiliary acid scan, 30 days of antisecretory therapy with omeprazole (40 mg daily), and repeat GBEF on day 30. Subjects were surveyed regarding compliance and symptoms. RESULTS For 15 of 19 subjects, PPI therapy was associated with reduced gallbladder motility. Evolution of symptoms consistent with a biliary etiology was reported by 26.7% of these subjects. CONCLUSIONS Short-term PPI therapy reduces gallbladder motility in healthy volunteers. Chronic PPI therapy may pose a risk for long-term gallbladder dysfunction and biliary complications.
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Affiliation(s)
- M A Cahan
- Department of Surgery, University of North Carolina at Chapel Hill, Campus Box 7081, Chapel Hill, North Carolina 27599-7081, USA
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Behar J, Corazziari E, Guelrud M, Hogan W, Sherman S, Toouli J. Functional gallbladder and sphincter of oddi disorders. Gastroenterology 2006; 130:1498-509. [PMID: 16678563 DOI: 10.1053/j.gastro.2005.11.063] [Citation(s) in RCA: 169] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Accepted: 11/03/2005] [Indexed: 12/27/2022]
Abstract
The functional disorder of the gallbladder (GB) is a motility disorder caused initially either by metabolic abnormalities or by a primary motility alteration. The functional disorders of the sphincter of Oddi (SO) encompass motor abnormalities of either the biliary or the pancreatic SO. Dysfunction of the GB and/or biliary SO produce similar patterns of pain. The pain caused by a dysfunction of the pancreatic SO can be similar to that of acute pancreatitis. The symptom-based diagnostic criteria of motility dysfunction of the GB and biliary SO are episodes of moderate to severe steady pain located in the epigastrium and right upper abdominal quadrant that last at least 30 minutes. GB motility disorder is suspected after gallstones and other structural abnormalities have been excluded. This diagnosis should then be confirmed by a decreased GB ejection fraction induced by cholecystokinin at cholescintigraphy and after disappearance of the recurrent biliary pain after cholecystectomy. Symptoms of biliary SO dysfunction may be accompanied by features of transient biliary obstruction, and those of pancreatic SO dysfunction are associated with elevation of pancreatic enzymes and even pancreatitis. Biliary-type SO dysfunction is more frequently recognized in postcholecystectomy patients. SO manometry is valuable to select patients with sphincter dysfunction; however, because of the high incidence of complications, these patients should be referred to an expert unit for such assessment. Thus invasive tests should be performed only in the presence of compelling clinical evidence and after noninvasive testing has yielded negative findings. The committee recommends that division of the biliary or pancreatic sphincters only be considered when the patient has severe symptoms, meets the required criteria, and other diagnoses are excluded.
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Affiliation(s)
- Jose Behar
- Rhode Island Hospital and Brown University School of Medicine, Providence, Rhode Island 02903, USA.
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