University of Wisconsin–Madison

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.

  • Episodes of right upper quadrant pain
  • Severe pain that limits activities of daily living
  • Nausea associated with episodes of pain
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.

These include:

  • Pain episodes that last longer than 30 minutes
  • Recurrent symptoms that occur at variable intervals
  • Pain that is severe enough to interrupt daily activity or lead to ER visits
  • Pain that builds up to a steady level
  • Pain that is not relieved by bowel movements, postural changes, or antacids
  • Exclusion of other structural diseases that could explain the symptoms
  • Other supportive criteria include: association of pain with nausea and vomiting, radiation of the pain to the infrascapular region, and pain that wakes the patient in the middle of the night.
  • Normal liver enzymes, conjugated bilirubin, and amylase/lipase.
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.

  • Performance of the test only on an outpatient basis
  • NPO status 4-6 hours before testing
  • No opiates for 4 half-lives of the drug or 6 hours prior to the study
  • Withholding other drugs which affect gallbladder motility including:
    • Calcium channel blockers
    • Octreotide
    • Progesterone
    • Indomethacin
    • Theophylline
    • Benzodiazepines
    • H2 blockers
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)

  • Patients with atypical symptoms who have an abnormal HIDA scan will not necessarily benefit from cholecystectomy as other etiologies (e.g. IBSGERD, functional bowel and motility disorders) are more likely.

Failure to adequately exclude other structural diseases that could explain the symptoms

  • Although controversial, most experts recommend performance of an upper endoscopy prior to cholecystectomy for biliary dyskinesia to rule out other structural disorders of the upper GI tract (esophageal strictures, gastric and duodenal ulcers, H pylori, etc).

Performance of a HIDA scan while the patient is acutely ill or on medications that inhibit gallbladder function

  • Because of the functional nature of the HIDA scan, it is easily impacted by patient factors and should not be performed except under the conditions listed above.

Failure to obtain complete laboratory studies (liver enzymes, conjugated bilirubin, amylase/lipase)

  • In order to exclude other disorders of the liver and pancreas, all patients should have normal laboratory studies prior to making a diagnosis of biliary dyskinesia.
Treatment Options

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%.

 

For More Information

For more information about the surgical treatment of biliary dyskinesia at UW Health, please visit our liver and pancreas program here.

References

1. Functional Hepatobiliary Disease: Chronic Acalculous Gallbladder and Chronic Acalculous Biliary Disease. Ziessman, H.A. Semin Nucl Med. 2006; 36:119-132.
2. Diagnostic Stringency and Healthcare Needs i nPatients with Biliary Dyskinesia. Aggarwal, N., Bielfeldt, K. Dig Dis Sci. 2013 Oct; 58(10):2799-808.
3. Utilization of Cholecystokinin Cholescintigraphy in Clinical Practice. Richmond et al. J Am Coll Surg. 2013 Aug;217(2):317-23.
4. Functional Gallbladder and Sphincter of Oddi Disorders. Behar et el. Gastroenterology. 2006 Apr;130(5):1498-509.