Biliary dyskinesia
Discuss biliary dyskinesia?
Some patients present with typical biliary colic but without gallstones on ultrasonography. These patients either have small stones (microlithiasis) or sludge that were missed on conventional imaging studies or other causes of biliary symptoms unrelated to gallstones such as sphincter of Oddi dysfunction, dyspepsia, irritable bowel syndrome or biliary dyskinesia.
Discuss the diagnosis?
- Exclude other causes as above. An OGD is usually performed to exclude peptic ulcer, reflux or gastritis.
- EUS may help to exclude microlithiasis
- Cholescintigraphy or HIDA scan- In this technique, the radio labelled tracer (HIDA or hepatobiliary imino diacetic acid) is injected intravenously and excreted in bile. Images are obtained using the gamma camera over a period of time and can be relied upon as functional images. The gallbladder ejection fraction can be computed and compared to the normal range. Biliary dyskinesia was defined by a gallbladder ejection fraction of less than 50 percent on HIDA scan in conjunction with typical clinical symptoms.
Discuss the treatment?
An abnormal gallbladder emptying (measured as the gallbladder ejection fraction) has been proposed as an indication that cholecystectomy would help relieve symptoms of typical biliary pain in patients without gallstones or sludge on imaging studies. A number of reports have described surgical outcomes in patients with abnormal gallbladder contractility as assessed by a HIDA scan. However the results are conflicting. Thus a low gallbladder ejection fraction is not a reliable indicator of clinical outcomes. Thus, the differential diagnosis in these patients with a low gallbladder ejection fraction should still include functional dyspepsia, irritable bowel syndrome, small intestinal bacterial overgrowth, and sphincter of Oddi dysfunction, all of which should be considered before recommending a cholecystectomy.
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