The Treatment of Gallbladder Dyskinesia Based Upon Symptoms

Functional gastrointestinal disorders. Overlap syndrome Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine and Gastroenterological Scientific Society of Russia

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Diagnoses of Exclusion in the Workup of Abdominal Complaints

Abdominal pain is a common complaint in the emergency department, comprising 8.8% of all visits. Despite advances in medicine and imaging, 20% to 30% of patients still leave the department without a definitive diagnosis, whichhis can be both distressing for patients and unsatisfying for providers. Diagnoses of exclusion can be perilous, and their application should be carefully considered in order to not overlook more emergent complaints. However, a working knowledge of diagnoses of exclusion can guide therapeutics and specialty referrals that can ultimately provide answers and relief to a patient population often at odds with available information and expectations.

Biliary hyperkinesia in adolescents-it isn't all hype!

Background

Biliary dyskinesia generally refers to a hypofunctioning gallbladder with an ejection fraction (EF) of <35% on hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (CCK-HIDA testing). In adults, biliary hyperkinesia has a defined association with biliary colic symptoms and can be relieved with surgical intervention. This clinical entity has not been well described in children or adolescents. In fact, only recently have we seen biliary hyperkinesia on HIDA at our centers. To that end, we reviewed our recent experience with adolescents who have presented and been treated for this unusual clinical entity.

Methods

With IRB approval, we retrospectively reviewed the records of all patients with abnormally high HIDA EFs (>80%) cared for by the pediatric surgery services at two tertiary care centers over the span of a three-year period. Age, sex, BMI, CCK-HIDA results, and preoperative testing and post-operative pathology were noted. Resolution of symptoms was determined by subjective patient self-reporting at postoperative visit.

Results

Eighteen patients met inclusion criteria. Average age 15.7 (range, 10-17 years), median BMI 27.3 (±8.2). Fifteen patients were female and 3 were male. Average CCK-HIDA EF was 91.6% (±5.2), 82.4% of the patients had evidence of chronic cholecystitis and/or cholesterolosis on pathology. Postoperatively, 82.4% of the patients available for follow up (n=17) reported complete or near complete resolution of symptoms.

Conclusions

Biliary hyperkinesia is an emerging clinical entity in children and adolescents and has a similar presentation to biliary hypokinesia. While the pathophysiologic mechanism of pain is not fully elucidated, laparoscopic cholecystectomy appears to provide a surgical cure for these patients and should be considered in the differential for the patient with an unremarkable workup and history suggestive of biliary colic.

Systematic review and meta-analyses of cholecystectomy as a treatment of biliary hyperkinesia

Biliary hyperkinesia is typically diagnosed in patients with biliary-like pain and no evidence of gall stones on imaging modalities but who have had biliary scintigraphy scan (HIDA) that shows ejection fraction ≥ 80%. This study aims to identify whether the removal of the gall bladder can alleviate the symptoms associated with biliary hyperkinesia. Systematic search following PRISMA guidelines was done from inception to January 2020 using PubMed/Medline, OVID, Embase, Cochrane database of systemic reviews, Cochrane central register of controlled trials, The Database of Abstracts of Reviews of Effects (DARE) and Cochrane library databases. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardized MD (SMD) for continuous outcomes. A meta-analysis was done using random-effect model in RevMan 5.4^® software. Thirteen studies met the inclusion criteria and were included in the review. A total of 332 patients diagnosed with biliary hyperkinesia underwent cholecystectomy, of whom 303 (91.3%) reported symptomatic improvement RR 8.67 (95% CI 4.95, 15.16) P = 0.01. Six studies described abnormal histological features in 163/181 (90.05%) with high GB EF. RR 7.88 (95% CI 3.94, 15.75) P = 0.08. Chronic cholecystitis n = 155 (95%), cholesterolosis n = 7 (4.3%), and one showed features of acute cholecystitis. Patients with typical biliary colic symptoms without gallstones and markedly high ejection fraction might benefit from having cholecystectomy to alleviate their symptoms.

Optimal hepatobiliary scintigraphy for gallbladder dyskinesia

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.

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Use of a fatty meal as a stimulant for hepatobiliary iminodiacetic acid scan.

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Affordable alternative to cholecystokinin for a hepatobiliary iminodiacetic acid scan.

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Comparison of 2 stimulants used for hepatobiliary iminodiacetic acid scan.

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Reliable alternative to IV cholecystokinin for hepatobiliary iminodiacetic acid scans.

Surgical referral for cholecystectomy in patients with atypical symptoms

BACKGROUND

Cholelithiasis referrals often present with concomitant or isolated atypical symptoms such as reflux, bloating, or epigastric pain. We sought to identify the impact of preoperative symptomatology of atypical or dyspepsia-type biliary colic on operative and non-operative clinical outcomes.

METHODS

A retrospective review of patients referred for gallstone disease from 2014 to 2018 at a single institution in Los Angeles County was performed.

RESULTS

Of 746 patients evaluated for gallstone disease, 87.4% (n = 652) underwent cholecystectomy - 90.8% (n = 592) had symptom resolution postoperatively whereas 9.2% (n = 60) did not. Over half presented with concomitant atypical and/or dyspepsia symptoms (n = 411). Heartburn/reflux was significantly associated with unresolved symptoms postoperatively (OR 2.1,1.0-4.4, p = 0.04). Overall, 11.1% (n = 83) of all 746 patients and 20.2% of patients with atypical and/or dyspepsia symptoms improved with medical management of gastritis or Helicobacter pylori triple therapy pre/post-operatively.

CONCLUSION

Atypical biliary colic and/or dyspepsia is associated with unresolved symptoms following cholecystectomy. Such patients may benefit from H. pylori testing or PPI trial prior to cholecystectomy.

Cholescintigraphy may have a role in selecting patients with biliary dyskinesia for cholecystectomy: a systematic review

BACKGROUND

Patients with typical biliary pain, no gallstones on ultrasound and low gallbladder ejection fraction (GBEF) on cholescintigraphy (gallbladder dyskinesia) may be considered for a laparoscopic cholecystectomy. However, some studies have suggested that symptoms alone are an adequate indication for laparoscopic cholecystectomy. The aim was to determine the role of cholescintigraphy in predicting outcomes of cholecystectomy in patients with typical and atypical biliary symptoms and normal biliary ultrasound.

METHODS

Meta-analysis using Preferred Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines of published literature using several electronic databases.

RESULTS

Twenty-four articles were selected with a total of 1710 patients. The majority (n = 1633, 94.4%) of patients had typical biliary symptoms. A total of 1047 patients with typical symptoms and a reduced GBEF had a cholecystectomy with 852 (81.4%) having complete resolution of symptoms. A total of 148 with typical symptoms and normal GBEF had a cholecystectomy with 103 (69.5%) having complete resolution, which was significantly less than those with a reduced GBEF (odds ratio 1.65, confidence interval 1.08-2.05, P = 0.01). Forty-five patients with atypical symptoms and a reduced GBEF had a cholecystectomy with 31 (68.9%) having complete resolution of symptoms, which is significantly lower than those with typical symptoms (odds ratio 1.97, confidence interval 0.95-3.90, P = 0.05).

CONCLUSION

Cholescintigraphy improved the predication of outcome of cholecystectomy in biliary dyskinesia by 10%. However, the presence of typical symptoms does predict an effective response in 70% of patients. Atypical symptoms predict a poorer response.

Decision analysis and reinforcement learning in surgical decision-making

BACKGROUND

Surgical patients incur preventable harm from cognitive and judgment errors made under time constraints and uncertainty regarding patients' diagnoses and predicted response to treatment. Decision analysis and techniques of reinforcement learning theoretically can mitigate these challenges but are poorly understood and rarely used clinically. This review seeks to promote an understanding of decision analysis and reinforcement learning by describing their use in the context of surgical decision-making.

METHODS

Cochrane, EMBASE, and PubMed databases were searched from their inception to June 2019. Included were 41 articles about cognitive and diagnostic errors, decision-making, decision analysis, and machine-learning. The articles were assimilated into relevant categories according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.

RESULTS

Requirements for time-consuming manual data entry and crude representations of individual patients and clinical context compromise many traditional decision-support tools. Decision analysis methods for calculating probability thresholds can inform population-based recommendations that jointly consider risks, benefits, costs, and patient values but lack precision for individual patient-centered decisions. Reinforcement learning, a machine-learning method that mimics human learning, can use a large set of patient-specific input data to identify actions yielding the greatest probability of achieving a goal. This methodology follows a sequence of events with uncertain conditions, offering potential advantages for personalized, patient-centered decision-making. Clinical application would require secure integration of multiple data sources and attention to ethical considerations regarding liability for errors and individual patient preferences.

CONCLUSION

Traditional decision-support tools are ill-equipped to accommodate time constraints and uncertainty regarding diagnoses and the predicted response to treatment, both of which often impair surgical decision-making. Decision analysis and reinforcement learning have the potential to play complementary roles in delivering high-value surgical care through sound judgment and optimal decision-making.

Relations between hepatobiliary scintigraphy findings and histopathological factors in patients with recurrent biliary colic

BACKGROUND/PURPOSE

The aim of the present study was to investigate the relationship between hepatobiliary scintigraphy findings and histopathological results in patients with recurrent biliary colic.

METHODS

We retrospectively enrolled 107 patients who underwent hepatobiliary scintigraphy for recurrent biliary colic and subsequent cholecystectomy. According to the hepatobiliary scintigraphy findings, patients were categorized into a nonvisualization of gallbladder activity (nonvisualized GB) group, low gallbladder ejection fraction (GBEF) group, and normal GBEF group. Differences in histopathologic factors between the three groups were evaluated and multivariate logistic regression analyses were performed to identify histopathological predictors for hepatobiliary scintigraphy findings.

RESULTS

The nonvisualized group had a higher frequency of patients with empyema and severe infiltration by neutrophils, lymphoplasma cells, and eosinophils. The low GBEF group had a higher muscle-to-total wall thickness ratio and muscle-to-fibrosis thickness ratio of the gallbladder wall than those in the normal GBEF group. On multivariate logistic regression analyses, severe degrees of lymphoplasma cell infiltration and eosinophil infiltration were independent predictors for nonvisualization of gallbladder activity, and a higher muscle-to-fibrosis thickness ratio was an independent predictor for low GBEF.

CONCLUSIONS

In patients with recurrent biliary colic, nonvisualization of gallbladder activity on hepatobiliary scintigraphy was related to the degree of inflammation in the gallbladder, while low GBEF was related to muscular hypertrophy of the gallbladder.

Role of laparoscopic cholecystectomy in the management of chronic right upper quadrant pain due to biliary dyskinesia: a systematic review and meta-analysis

Background

The objective of this study was to evaluate the surgical outcomes and feasibility of performing laparoscopic cholecystectomy (LC) in patients with longstanding right upper quadrant pain secondary to biliary dyskinesia.

Methods

A systematic review of the literature including published randomized, controlled trials, non-randomized trials and comparative trials of any type, reporting outcomes of LC in the management of chronic right upper quadrant pain in patients with biliary dyskinesia, using the principles of meta-analysis on RevMan 5.3 statistical software, was undertaken.

Results

Thirteen studies including 740 patients evaluating the symptomatic improvement following LC in patients with biliary dyskinesia presenting as chronic right upper quadrant pain were included. There were 542 patients in LC group and 198 patients in Non-LC group. Successful complete resolution of symptoms was more likely to be achieved in LC group [risk ratio (RR), 0.21; 95% confidence interval (CI), 0.09-0.50, P=0.00001]. In addition, the risk of failure to resolve symptoms (risk ratio, 0.15; 95% CI, 0.05-0.39, P=0.00001) was lower in LC group.

Conclusions

LC may be considered as an acceptable surgical intervention in patients with biliary dyskinesia presenting with chronic right upper quadrant pain. Currently there is insufficient evidence to recommend the routine use of LC in every patient with biliary dyskinesia. Paucity of high power randomised, controlled trials is the major reason for this lack of evidence which should be addressed soon and until then current study may be used to provide the basis for offering LC in selected group of patients.

Systematic review with meta-analysis: cholecystectomy for biliary dyskinesia-what can the gallbladder ejection fraction tell us?

BACKGROUND

Gallbladder dyskinesia (gallbladder spasm, biliary dyskinesia or chronic acalculous cholecystitis) is a poorly defined entity which presents as biliary-type pain without any identifiable organic pathology. Abnormal gallbladder ejection fraction (GBEF) is used by some to select those likely to benefit from cholecystectomy. The validity of this approach has been questioned.

AIM

To systematically review the literature and summarise the evidence surrounding the practice of cholecystectomy based on GBEF for gallbladder dyskinesia.

METHODS

We conducted a systematic search of PubMed/MEDLINE and SCOPUS from 1980 to 2016 to identify the relevant literature.

RESULTS

Twenty-nine studies including 2891 patients were included in the final analysis. In comparing cholecystectomy with medical management, patients with a normal GBEF did not benefit from cholecystectomy; whereas those with low GBEF had a higher chance (RR, relative risk = 2.37) of symptomatic improvement following surgery. When those classified as "low" and "normal" GBEF were compared in terms of outcome following cholecystectomy, the rate of improvement following surgery was similar in the two groups (RR 1.09) which suggests a placebo effect of surgery.

CONCLUSIONS

While a low GBEF may provide some guidance in identifying those with gallbladder dyskinesia who may benefit from cholecystectomy, the available data are inconsistent and based on studies of poor quality which are often subject to bias and the impact of confounding factors. For these reasons, we conclude that the role of scintigraphy and cholecystectomy in the definition and management of this disorder remain unclear pending definitive study.

Epigastric symptoms of gallbladder dyskinesia mistaken for functional dyspepsia: Retrospective observational study

Functional dyspepsia (FD) is a constellation of epigastric symptoms originating in the gastroduodenal region without organic and metabolic cause. However, similar confounding symptoms can also appear in patients with gallbladder (GB) dyskinesia. Therefore, symptoms of GB dyskinesia may be mistaken for FD. We aimed to identify GB dyskinesia as a cause of FD symptoms compatible with the Rome IV criteria and the need for an evaluation of GB function in patients with FD symptoms.We investigated information of patients with FD symptoms who underwent a quantitative Tc-diisoproyl iminodiacetic acid cholescintigraphy (DISIDA scan) through electronic medical records, and GB dyskinesia was judged to be the cause of the FD symptoms if the symptoms disappeared as GB function normalized on the follow-up DISIA scan in patient with decreased GB function on the initial DISIDA scan.A total of 275 patients underwent a DISIDA scan. Eighteen patients of them had FD symptoms compatible with the Rome IV criteria. Three were lost after undergoing a DISIDA scan. Eight had normal GB function, and the other 7 had decreased GB function on the initial DISIDA scan. In 4 of the 7 patients with GB dyskinesia, FD symptoms disappeared as GB function normalized. As a result, GB dyskinesia was the cause of the symptoms in 4 of 18 patients with FD symptoms compatible with the Rome IV criteria.It is necessary to evaluate GB function in patients with refractory FD symptoms because the symptoms can be caused by GB dyskinesia.

Rome IV. Gallbladder and Sphincter of Oddi Disorders

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.

Gallbladder dysfunction: how much longer will it be controversial?

BACKGROUND

Motility disorders of the biliary tree [biliary dyskinesia, including both gallbladder dysfunction (GBD), and sphincter of Oddi dysfunction] are difficult to diagnose and to treat.

SUMMARY

There is controversy in the literature in particular regarding the criteria that should be used to select patients for cholecystectomy (CCY) in cases of suspected GBD. The current review covers the history, diagnosis, and treatment of GBD. Key Messages: Only >85% of patients with suspected GBD have relief following CCY, a much lower rate than the nearly 100% success rate following CCY for gallstone disease. Unfortunately, the literature is lacking, and there are no universally agreed-upon criteria for selecting which patients to refer for operation, although cholecystokinin (CCK)-enhanced hepatobiliary iminodiacetic acid scan is often used, with emphasis on an abnormally low gallbladder ejection fraction or pain reproduction at CCK administration. There is a clear need for large, well-designed, more definitive, prospective studies to better identify the indications for and efficacy of CCY in cases of GBD.

HIDA Scan with Ejection Fraction is over Utilized in the Management of Biliary Dyskinesia

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.

Management of gallbladder dyskinesia: patient outcomes following positive ⁹⁹mtechnetium (Tc)-labelled hepatic iminodiacetic acid (HIDA) scintigraphy with cholecystokinin (CCK) provocation and laparoscopic cholecystectomy

AIMS

To evaluate clinical outcomes in patients with typical biliary pain, normal ultrasonic findings, and a positive (99m)technetium (Tc)-labelled hepatic iminodiacetic acid analogue (HIDA) scintigraphy with cholecystokinin (CCK) provocation indicating gallbladder dyskinesia, as per Rome III criteria, undergoing laparoscopic cholecystectomy (LC).

METHODS AND MATERIALS

Consecutive patients undergoing LC for gallbladder dyskinesia were identified retrospectively. They were followed up by telephone interview and review of the electronic case records to assess symptom resolution.

RESULTS

One hundred consecutive patients (median age 44; 80% female) with abnormal gallbladder ejection fraction (GB-EF <35%) were followed up for a median of 12 months (range 2-80 months). Following LC, 84% reported symptomatic improvement and 52% had no residual pain. Twelve percent had persisting preoperative-type pain of either unchanged or worsening severity. Neither pathological features of chronic cholecystitis (87% of 92 incidences when histology available) nor reproduction of pain on CCK injection were significantly predictive of symptom outcome or pain relief post-LC.

CONCLUSION

In one of the largest outcome series of gallbladder dyskinesia patients in the UK with a positive provocation HIDA scintigraphy examination and LC, the present study shows that the test is a useful functional diagnostic tool in the management of patients with typical biliary pain and normal ultrasound, with favourable outcomes following surgery.

Gallbladder ejection fraction declines with age in patients undergoing cholecystectomy for acalculous biliary symptoms but has low accuracy in the prediction of gallbladder pathology

BACKGROUND/AIMS

Hepatobiliary Iminodiacetic Acid (HIDA) scan provides a technique to quantify gallbladder ejection fraction (EF) in patients suffering acalculous biliary colic (ACBC). We wished to evaluate the accuracy of EF in the prediction of gallbladder pathology in patients undergoing cholecystectomy.

METHODS

Data were retrieved from a database of patients referred for HIDA scan for ACBC, including EF and the pathological outcome of those undergoing cholecystectomy, and compared to normal values obtained from a review of related studies. Significant associations were demonstrated by chi-square, Mann-Whitney test, and linear regression. The predictive accuracy of different cut-offs of EF was demonstrated by the ROC curve analysis.

RESULTS

Of 83 patients referred for HIDA scan for ACBC, 41 underwent cholecystectomy. The median EF of this group (33%) was significantly lower than the composite normal median value from previous studies (56%). Thirty-two patients revealed evidence of gallbladder pathology. The EF declined with age (coefficient = -0.51, 95% CI = -0.99 to -0.33), but the median value did not differ between those with gallbladder pathology (34%) and those with normal gallbladders (29%).

CONCLUSION/DISCUSSION

Although an EF cut-off of 35% had the greatest accuracy in the prediction of pathology of those tested (0.56), the poor negative predictive value (23.5%) was a major contributor to its low accuracy. Although patients with ACBC have reduced gallbladder EF compared to the normal population, its quantitative assessment is of limited value in the prediction of gallbladder pathology.

Cholecystectomy for biliary dyskinesia: how did we get there?

BACKGROUND

The focus of biliary dyskinesia (BD) shifted within the last 30 years, moving from symptoms after cholecystectomy (CCY) to symptoms with morphological normal gallbladder, but low gallbladder ejection fraction.

METHODS

We searched the pubmed database to systematically review studies focusing on the diagnosis and treatment of gallbladder dysfunction.

RESULTS

Impaired gallbladder contraction can be found in about 20% of healthy controls and an even higher number of patients with various other disorders. Surgery for BD increased after introduction of laparoscopic CCY, with BD now accounting for >20% of CCY in adults and up to 60% in pediatric patients. The majority of cases reported were operated in the USA, which differs from surgical series for cholelithiasis. Postoperative outcomes do not differ between groups with abnormal or normal gallbladder function.

CONCLUSION

Functional gallbladder testing should not be seen as an indicator of relevant biliary tract disease or prognostic marker to identify patients who may benefit from operative intervention. Instead biliary dyskinesia should be considered as a part of a spectrum of functional disorders, which are generally managed conservatively. Small proof of concept studies have demonstrated effects of medical therapy on biliary dysfunction and should thus be never tested in appropriately designed trials.

Pain provocation and low gallbladder ejection fraction with CCK cholescintigraphy are not predictive of chronic acalculous gallbladder disease symptom relief after cholecystectomy

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.

Biliary dyskinesia and symptomatic gallstone disease in children: two sides of the same coin?

BACKGROUND

Despite lack of consensus criteria, biliary dyskinesia (BD) is an increasingly accepted pediatric diagnosis.

AIMS

We compared patient characteristics, outcomes, and resource utilization (before and after surgery) between children with BD and symptomatic cholecystolithiasis (LITH).

METHODS

Data from the electronic medical record were abstracted for children diagnosed with BD or LITH between December 1, 2002, and November 30, 2012, at Children's Hospital of Pittsburgh.

RESULTS

Four hundred and ten patients were identified (BD: 213 patients, LITH: 197 patients). Patients with BD had significantly lower BMI, longer symptom duration, more dyspeptic symptoms, and were more likely to present with other symptoms. Forty-one patients (13.8%) with BD underwent cholecystectomy despite a normal gallbladder ejection fraction (GB-EF). In 32 of these, sincalide triggered pain compared to 75 of the 155 patients with low GB-EF. After surgery, patients with BD more commonly visited gastroenterology clinics and had more GI-related hospitalizations, while emergency room visits decreased in both groups. Only the nature of biliary disease independently predicted continuing pain after surgery, which in turn was the best predictor for higher resource utilization after cholecystectomy.

CONCLUSIONS

A large percentage of children with BD did not meet the adult diagnostic standards. Compared to those with LITH, children with BD have more widespread symptoms and continue to use more clinical resources after surgery. These findings suggest that despite its benign prognosis, BD is increasingly treated like other potentially acute gallbladder diseases, although it has the typical phenotype of FGIDs and should be treated using approaches used in such disorders.

Laparoscopic cholecystectomy for biliary dyskinesia: Which patients have long term benefit?

PURPOSE

Biliary dyskinesia (BD) is described as biliary colic in the absence of gallstones. The diagnosis relies on imaging studies and decreased excretion of bile in response to cholecystokinin during quantitative cholescintigraphy. The purpose of this study was to evaluate the success of laparoscopic cholecystectomy (LC) for relieving symptoms in patients diagnosed with BD and correlate gallbladder ejection fraction (EF) with symptom relief.

METHODS

A retrospective review was performed at a single institution of all patients who underwent LC for BD from January 2005 through January 2012. The diagnosis of BD was determined by a normal gallbladder as viewed with ultrasonography and cholescintigraphy with a gallbladder EF less than or equal to 45%. Data collection included demographics, results of imaging studies, pathologic diagnosis, and early postoperative pain relief. Patients were contacted by phone after being discharged from the surgeon's care for evaluation of symptom relief. Data were analyzed with nonparametric statistical methods, including Mann-Whitney U test, receiver operator characteristic, Fisher exact test, and χ(2) test. All data are expressed as median and 25th and 75th percentile range.

RESULTS

There were 126 patients who had a LC for BD during the study period. The median biliary EF was 20% (10-29%). The most common pathologic finding was chronic cholecystitis (n = 95; 75%). Median length of follow-up in the perioperative period was 11 days (8-17), during which time 98 patients (78%) had relief of symptoms. Phone interviews (n = 53; 42%) confirmed 66% (n = 35) of patients remained free of pain. There was no difference in the mean EF among those with resolution of pain 20% (10-29%) compared with patients with persistent pain 23% (11-29%), P = .62. Obese patients were more likely to have persistent symptoms in the perioperative period with a shift to lower body mass index at the time of the phone survey. Receiver operator characteristic characteristic for the association between scintigraphic EF and resolution of postoperative pain demonstrated no association, with the area under the curve equal to 0.47.

CONCLUSION

The majority of patients in this series with BD had resolution of symptoms with LC. However, cholescintigraphy EF did not correlate with outcome. Further studies are needed to better identify patients diagnosed with BD who will benefit from LC.

Diagnostic stringency and healthcare needs in patients with biliary dyskinesia

AIM

We have recently shown an increase in cholecystectomies for biliary dyskinesia. Based on these results, we hypothesized that diagnostic criteria are less stringently applied which may contribute to ongoing resource utilization.

METHODS

Using billing codes, patients seen for biliary dyskinesia were identified and data were extracted from the electronic medical record to confirm the diagnosis, obtain demographic and clinical data and assess resource utilization 1 year prior to and after cholecystectomy.

RESULTS

A total of 972 patients were identified, with 894 undergoing cholecystectomy. In 259 patients, symptoms had started <3 months prior to evaluation. Functional gallbladder imaging revealed a mean gallbladder ejection fraction of 23.1 ± 0.7 %; of the patients undergoing surgery, 116 had a normal gallbladder ejection fraction. Sufficient up data for pre- and post-operative assessment of resource utilization was available for 368 patients. Emergency room (ER) visits decreased from 0.86 ± 0.07 to 0.69 ± 0.03 (P < 0.05), while hospitalization rates remained unchanged after surgery. Patients not meeting consensus criteria for the diagnosis of biliary dyskinesia were more likely to use opioids and have ER visits prior to and after cholecystectomy. Using multiple logistic regression benzodiazepine use, migraine history and prior ER visits independently predicted postoperative resource utilization.

CONCLUSIONS

Our data demonstrate that a significant number of patients undergo cholecystectomy for biliary dyskinesia, even though they do not meet currently accepted diagnostic criteria. While healthcare resource utilization drops within the first year after surgery, ER visits and hospitalizations remain common, suggesting a more limited benefit of surgical approaches in these patients.

Normokinetic biliary dyskinesia: a novel diagnosis

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.

Pathologic changes in biliary dyskinesia

PURPOSE

For children with upper abdominal pain and evaluation for acalculous biliary disease, laparoscopic cholecystectomy is an accepted treatment with inconsistent outcomes. The purpose of this study was to identify predictors of outcomes.

METHODS

One hundred sixty-seven children underwent laparoscopic cholecystectomy at a single children's hospital. Radiographic findings, histopathology, family history, and demographics (sex, age, height, weight, body mass index-for-age percentile) were evaluated as predictors of postoperative symptomatic resolution using a binomial probability model. The data for radiologic studies and pathologic specimens were obtained via re-review in a blinded fashion.

RESULTS

Of 167 children, 43 (25.7%) had a preoperative diagnosis of biliary dyskinesia and 41 (95.3%) had documented follow-up. Mean follow-up was 8.4 months. Twenty-eight patients (68.3%) had symptom resolution. Ejection fraction less than or equal to 15%, pain upon cholecystokinin injection, and a family history of biliary disease were not predictors of symptomatic resolution. Nonoverweight patients (body mass index-for-age <85th percentile) were more likely to have symptom resolution than their overweight counterparts (odds ratio, 2.13). Most patients (68.3%) had a pathologic gallbladder on blinded review. However, this did not correlate with outcome.

CONCLUSIONS

Most gallbladders removed for biliary dyskinesia are pathologic. Being overweight can be considered a relative contraindication to cholecystectomy for biliary dyskinesia.

Gallbladder dyskinesia: fact or fiction?

Gallbladder dyskinesia is a functional (motility) disorder of the gallbladder resulting in episodic abdominal pain that, in carefully selected cases, resolves with cholecystectomy. It is a diagnosis of exclusion: several functional and organic disorders have to be excluded, and confounding factors addressed, before a diagnosis of gallbladder dyskinesia can be entertained. The combination of high clinical suspicion and an abnormally low gallbladder ejection fraction on cholecystokinin stimulated-cholescintigraphy predict benefit from removing the gallbladder.

The cholecystokin provocation HIDA test: recreation of symptoms is superior to ejection fraction in predicting medium-term outcomes

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.

Functional gallbladder disorder: gallbladder dyskinesia

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.