Management of Biliary Dyskinesia
Biliary dyskinesia is an enigmatic but important condition to consider in the evaluation of patients with right upper quadrant pain. A thorough history, work-up and examination are needed, as this diagnosis is primarily a diagnosis of exclusion. Proper selection of patients for cholecystectomy is essential in order to avoid unnecessary operative intervention.
What is biliary dyskinesia?
Biliary dyskinesia is a symptomatic functional disorder of the gallbladder whose precise etiology is unknown. It may be due to metabolic disorders that affect the motility of the GI tract, including the gallbladder, or to a primary alteration in the motility of the gallbladder itself. Biliary dyskinesia presents with a symptom complex that is similar to those with biliary colic.
What are the symptoms?
Biliary dyskinesia presents with a symptom complex that is similar to those with biliary colic.
How is it diagnosed?
In order to diagnose biliary dyskinesia, the patient should have right upper quadrant pains similar to biliary colic but have a normal ultrasound examination of the gallbladder (no stones, sludge, microlithiasis, gallbladder wall thickening or CBD dilation). For patients who are suspected to have biliary dyskinesia, the Rome III diagnostic criteria for functional gallbladder disorders should be considered.
When and how should a HIDA scan be obtained?
If a patient meets these criteria and has a normal ultrasound examination, a HIDA scan should be considered. Recently updated criteria for the performance of hepatobiliary scintigraphy should be followed to determine the gallbladder ejection fraction. These guidelines recommend imaging and CCK infusion at a slow and constant rate (0.02 micrograms/kg) over 60 minutes. Also included are important clinical considerations prior to testing.
Who should have a cholecystectomy?
Patients who have episodes of biliary type right upper quadrant pain, without structural abnormalities by ultrasound and an abnormal HIDA scan should be considered for cholecystectomy. An abnormal ejection fraction is considered to be less than 38% when the test is administered according to the guidelines described above. Some authors and experts recommend that the symptom complex should also be of sufficient duration (i.e. at least three months) before considering cholecystectomy.
Common pitfalls in the diagnosis of biliary dyskinesia
Performance of a HIDA scan in the absence of the symptom complex outlined above (Rome III criteria)
Failure to adequately exclude other structural diseases that could explain the symptoms
Performance of a HIDA scan while the patient is acutely ill or on medications that inhibit gallbladder function
Failure to obtain complete laboratory studies (liver enzymes, conjugated bilirubin, amylase/lipase)
Cholecystectomy is the only known effective treatment for the diagnosis of biliary dyskinesia. A period of observation can and should be offered however if the symptom complex has been of short duration or there remains concern that other etiologies may be the primary contributor to the patient’s symptoms. A trial of medical therapy and/or dietary manipulation should be considered for those thought to have functional bowel motility issues.
How effective is cholecystectomy for biliary dyskinesia?
Although initial studies in the early 1990s suggested that 80-90% of patients have symptom resolution with cholecystectomy, this has not held up in clinical practice. The likelihood of symptom relief at one year after cholecystectomy is variable and highly dependent on patient selection but ranges from 50-70%.
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For More Information
For more information about the surgical treatment of biliary dyskinesia at UW Health, please visit our liver and pancreas program here.
1. Functional Hepatobiliary Disease: Chronic Acalculous Gallbladder and Chronic Acalculous Biliary Disease. Ziessman, H.A. Semin Nucl Med. 2006; 36:119-132.