Diagnosis of gallbladder dyskinesia by quantitative hepatobiliary scintigraphy

[The effect of endoscopic sphincterotomy on the motility of the gallbladder and of the sphincter of Oddi in patients with acalculous biliary pain syndrome]

INTRODUCTION

Sphincter of Oddi dysfunction usually occurs after cholecystectomy, but it can sometimes be detected in patients with intact gallbladder too. The diagnostic value of the non-invasive functional tests is not established in this group of patients and the effects of sphincterotomy on transpapillary bile outflow and gallbladder motility are unknown.

AIMS

The aim of this study was to determine the effect of endoscopic sphincterotomy on the gallbladder ejection fraction, transpapillary bile outflow and the clinical symptoms of patients with acalculous biliary pain syndrome.

PATIENTS AND METHODS

36 patients with acalculous biliary pain syndrome underwent quantitative hepatobiliary scintigraphy, and all of them had decreased cholecytokinin-induced gallbladder ejection fraction. The endoscopic manometry of the sphincter of Oddi showed abnormal sphincter function in 26 patients who were enrolled the study. Before and after endoscopic sphincterotomy all patients had ultrasonographic measurement of cholecystokinin-induced gallbladder ejection fraction with and without nitroglycerin pretreatment and scintigraphy was repeated as well. The effects of sphincterotomy on gallbladder ejection fraction and transpapillary biliary outflow were evaluated. In addition, changes in biliary pain score with a previously validated questionnaire were also determined.

RESULTS

All 26 patients had decreased gallbladder ejection fraction before sphincterotomy measured with scintigraphy (19+18%) and ultrasound (16+9.7%), which was improved after nitroglycerin pretreatment (48.2+17%; p<0.005). Detected with both methods, the ejection fraction was in the normal range after sphincterotomy (52+37% and 40.8+16.5%), but nitroglycerin pretreatment failed to produce further improvement (48.67+22.2%, NS). Based on scintigraphic examination sphincterotomy significantly improved transpapillary biliary outflow (common bile duct half time 63±33 min vs. 37±17 min; p<0.05). According to results obtained from questionneries, 22 of the 26 patients gave an account of significant symptom improvement after sphincterotomy.

CONCLUSIONS

Endoscopic sphincterotomy improves cholecystokinin-induced gallbladder ejection fraction, transpapillary biliary outflow as well as biliary symptoms in patients with acalculous biliary pain syndrome and sphincter of Oddi dysfunction. Cholecystokinin-induced gallbladder ejection fraction with nitroglycerin pretreatment, measured with ultrasonography can be useful to select a subgroup of patients who can benefit from sphincterotomy.

Mandatory and optional function tests for biliary disorders

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.

Gastrointestinal manifestations of diabetes mellitus: spectrum of imaging findings

Diabetes mellitus is the most common multisystemic endocrine disorder. It can be complicated by several serious gastrointestinal manifestations that can be depicted by a variety of imaging methods. This article reviews the most commonly depicted gastrointestinal and hepatobiliary findings in patients with diabetes mellitus. These findings include motor dysfunction, biliary stasis with cholelithiasis and emphysematous cholecystitis, and fatty infiltration of the liver and pancreas.

Regional differences in the effects of various doses of cerulein upon the small-intestinal migrating motor complex in fasted and non-fasted sheep

There are no precise data concerning the effect of cerulein on the small-intestinal migrating motor complex (MMC) in sheep. Thus, the effort was directed towards the elucidation of the role of cerulein, a cholecystokinin (CCK) amphibian analogue, in the regulation of MMC cycle in conscious fasted and non-fasted sheep in various regions of the small intestine. In six sheep, equipped with bipolar electrodes in the entire small intestine and with one duodenal strain gauge force transducer in four of these animals, the continuous myoelectric and motor activity recordings were performed. During control period, two normal consecutive MMC cycles were recorded in fasted and non-fasted animals and then cerulein was slowly injected at the dose 1 (during 30 s), 10 (during 30 s or 60 s) or 100 ng/kg (during 30 s, 60 s or 120 s) or infused at the dose 0.5 or 1.5 ng/kg/min during 60 min. After cerulein administration at least two consecutive MMC cycles were also recorded. It was found that cerulein in moderate and higher doses injected in both fasted and non-fasted animals, especially during phase 2a or 2b MMC, inhibited phase 3 in the duodenum in at least one-third of the experiments and significantly increased the MMC cycle duration. The application of 100 ng/kg of cerulein during 120 s in the course of phase 2b MMC prolonged cycle duration from 70 +/- 21 to 113 +/- 19 min (p < 0.05) or from 51 +/- 18 to 113 +/- 19 min (p < 0.01) in fasted and non-fasted sheep respectively. The first phase 3 MMC arriving after cerulein administration at the highest dose was usually abnormal in approximately 60% of the experiments. The second phase 3 observed following the hormone injection was abnormal much less frequently and to the lesser extent. Furthermore, both cerulein doses significantly shortened the duration of phase 3 MMC either in fasted (from approximately 5.5-6.5 cpm to 4-5 cpm) or in non-fasted sheep (from approximately 4.5-5.5 to 3-4.5 cpm). The effects of cerulein exhibited the dose-response character. They were more pronounced when cerulein was injected during phase 2b or 2a MMC when compared with phase 1 MMC. The effects of cerulein on the ileal MMC were less evident, although the inhibition of the ileal phase 3 in response to both higher injected doses was observed occasionally. Infusions of cerulein in non-fasted sheep exerted similar effects as cerulein injections. It was stated that cerulein exerts marked regulatory effect upon the small-intestinal MMC in sheep. Although it remains uncertain whether the efficient doses of cerulein used in the present study correspond to physiological or pharmacological doses of CCK it seems likely that most of these doses were physiological. Thus, it is concluded that cerulein participates in the control of MMC cycles in the digestive and interdigestive states in sheep. It is possible that CCK is a physiological regulator of the ovine small-intestinal MMC.

Evaluation of the biliary tract in patients with functional biliary symptoms

The aim of this paper was to describe functional biliary syndromes and methods for evaluation of the biliary tract in these patients. Functional biliary symptoms can be defined as biliary symptoms without demonstrable organic substrate. Two main syndromes exist: Gallbladder dysfunction and sphincter of Oddi dysfunction. The most important investigative tools are cholescintigraphy and endoscopic sphincter of Oddi manometry. In gallbladder dysfunction a scintigraphic gallbladder ejection fraction below 35% can select patients who will benefit from cholecystectomy. Endoscopic sphincter of Oddi manometry is considered the gold standard in sphincter of Oddi dysfunction but recent development in scintigraphic methods is about to change this. Thus, calculation of hilum-to-duodenum transit time and duodenal appearance time on cholescintigraphy have proven useful in these patients. In conclusion, ambient methods can diagnose functional biliary syndromes. However, there are still a number of issues where further knowledge is needed. Probably the next step forward will be in the area of sensory testing and impedance planimetric methods.