Biliary hyperkinesia: an indication for cholecystectomy?

BACKGROUND: The main indications for laparoscopic cholecystectomy are stone-related diseases in adults. With a normal abdominal ultrasound (US), a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. Biliary dyskinesia or low gallbladder EF (EF < 35%) is a recognized indication for cholecystectomy. Recent articles report long-term resolution of symptoms in children with high EFs on the HIDA scan. The purpose of this study is to evaluate the response of patients with biliary colic and hyperkinetic gallbladder to cholecystectomy. We suggest that laparoscopic cholecystectomy might be a considerable surgical option in a subset of the adult population whose workup for food-related biliary abdominal pain is negative except for the high-value EF on HIDA scan. METHODS: Data were consecutively collected from all patients who underwent laparoscopic cholecystectomy between June 2012 and June 2019 at a single institution. Cases were identified using Current Procedural Terminology codes. Patients older than 17 years of age with the negative US (no stone, no sludge, no gallbladder wall thickening) and EF greater than 80% on cholecystokinin (CCK)-HIDA scan were included in this study. All patients were seen at 2 weeks and 10-16 months after surgeries. RESULTS: Over 7 years from June 2012 until June 2019, of 2116 patients who underwent laparoscopic cholecystectomy, 59 patients (2.78%) met study criteria. Postprandial abdominal pain was the most common symptom (43, 72.90%) followed by nausea/vomiting. Forty-seven patients (74.6%) had a reproduction of symptoms with CCK infusion. The average EF was 88.51%. Final pathology showed chronic cholecystitis in 41 (69.5%) patients, cholesterolosis in 13 (22%), polyp in 2 (3.4%). Thirty-six (61%) patients had complete resolution of symptoms, 9 (15%) patients had partial resolution, and 14 (24%) patients had no change. There was a complete resolution rate of 61% and an improvement rate of 76%. CONCLUSIONS: In patients with biliary symptoms, negative ultrasound, and elevated EF on HIDA scan (EF > 80%), laparoscopic cholecystectomy led to a significant rate of symptomatic relief. Interestingly, 94% also had unexpected pathologic findings. This disease process requires further analysis, but this could represent a new indication for laparoscopic cholecystectomy in the adult population.

Long-term results of cholecystectomy for biliary dyskinesia: outcomes and resource utilization.

BACKGROUND: The purpose of this study is to describe a cohort of pediatric patients undergoing cholecystectomy for biliary dyskinesia (BD) and characterize postoperative resource utilization. METHODS: Single-institution, retrospective chart review of pediatric patients after cholecystectomy for BD was done. Patient demographics and clinical characteristics as well as operative details and postoperative interventions were abstracted. Telephone follow-up was performed to identify persistent symptoms, characterize the patient experience, and quantify postoperative resource utilization. RESULTS: Forty-nine patients were included. Twenty-two patients (45%) were seen postoperatively by a gastroenterologist, of which, only 32% were known to the gastroenterologist before surgery. Postoperative studies included 13 abdominal ultrasounds for persistent pain, 13 esophagogastroduodenoscopies, five endoscopic retrograde cholangiopancreatographies (ERCPs), one endoscopic ultrasound, one magnetic resonance cholangiopancreaticogram, and five colonoscopies. Of the patients with additional diagnostic testing postoperatively, one had mild esophagitis, three had sphincter of Oddi dysfunction, and one was suspected to have inflammatory bowel disease. Telephone survey response rate was 47%. Among respondents, 65.2% reported ongoing abdominal pain, nausea, or vomiting at an average of 26 mo after operation. Of note, all patients who underwent postoperative ERCP with sphincterotomy reported symptom relief following this procedure. CONCLUSIONS: Relief of symptoms postoperatively in pediatric patients with BD is inconsistent. Postoperative studies, though numerous, are of low diagnostic yield and generate high costs. These findings suggest that the initial diagnostic criteria and treatment algorithm may require revision to better predict symptom improvement after surgery. Improvement seen after ERCP/sphincterotomy is anecdotal but appears to merit further investigation.

HIDA scan for functional gallbladder disorder: ensure that you know how the scan was done.

BACKGROUND: Despite the increasing use of fatty meal (FM) as a substitute for cholecystokinin (CCK) in pain reproduction during hepato-imino-diacetic acid (HIDA) scan in functional gallbladder disorder, there are no studies comparing the differences between CCK and FM. The present study was to compare the efficacy of FM in comparison of CCK in FGBD application. METHODS: Patients undergoing HIDA scans from August 2013 to May 2014 were divided into two groups: those undergoing CCK-stimulated HIDA scan versus FM-stimulated HIDA scan. These groups were compared according to demographics and HIDA results. RESULTS: Of 153 patients, 70 received CCK and 83 FM. There was no difference regarding age, gender, gallstones, gallbladder ejection fraction and time to visualization. However, significantly more of the patients receiving CCK than FM experienced pain reproduction (61% vs 30%, P<0.01). CONCLUSIONS: Stimulation of gallbladder contractility with a FM during HIDA is less than half as likely to reproduce biliary symptoms compared to CCK, despite similar ejection fractions and other parameters. It is essential that providers account for this difference when counseling patients regarding cholecystectomy for functional gallbladder disorder.

Gallbladder Ejection Fraction Is Unrelated to Gallbladder Pathology in Children and Adolescents.

OBJECTIVES: Biliary dyskinesia is a common diagnosis that frequently results in cholecystectomy. In adults, most clinicians use a cut off value for the gallbladder ejection fraction (GBEF) of <35% to define the disease. This disorder is not well characterized in children. Our aim was to determine the relation between GBEF and gallbladder pathology using a large statewide medical record repository. METHODS: We obtained records from all patients of 21 years and younger who underwent hepatic iminodiacetic acid (HIDA) testing within the Indiana Network for Patient Care from 2004 to 2013. GBEF results were obtained from radiology reports using data mining techniques. Age, sex, race, and insurance status were obtained for each patient. Any gallbladder pathology obtained subsequent to an HIDA scan was also obtained and parsed for mention of cholecystitis, cholelithiasis, or cholesterolosis. We performed mixed effects logistic regression analysis to determine the influence of age, sex, race, insurance status, pathologist, and GBEF on the presence of these histologic findings. RESULTS: Two thousand eight hundred forty-one HIDA scans on 2558 patients were found. Of these, 310 patients had a full-text gallbladder pathology report paired with the HIDA scan. GBEF did not correlate with the presence of gallbladder pathology (cholecystitis, cholelithiasis, or cholesterolosis) when controlling for age, sex, race, insurance status, and pathologist using a mixed effects model. CONCLUSIONS: Hypokinetic gallbladders are no more likely to have gallbladder pathology than normal or hyperkinetic gallbladders in the setting of a patient with both a HIDA scan and a cholecystectomy. Care should be used when interpreting the results of HIDA scans in children and adolescents.

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.

Acalculous cholecystitis or biliary dyskinesia for Epstein-Barr virus gallbladder involvement?

We present two patients with Epstein-Barr virus (EBV) infection related to gallbladder involvement. Such an association is already known as EBV induced acalculous cholecystitis, diagnosed on the basis of ultrasonographic findings. In our patients, radioisotopic cholescintigraphy was also performed and it showed that gallbladder was visualized in both patients in contrast to that what can be observed in cases of cholecystitis. However, the value of ejection fraction was compatible with biliary dyskinesia. We, therefore, consider that impaired gallbladder contractility in EBV infection cases may actually represent biliary dyskinesia and not acalculous cholecystitis taking into account the radioisotopic findings and the self limited course of the disorder.

[Imbalance of microelements and vitamins in adolescents with diffuse nontoxic goiter and biliary dyskinesia].

The purpose of the present work was to study the level of microelements and vitamins in adolescents with diffuse nontoxic goiter. It has been shown that comorbid biliary dyskinesia leads to significant dysregulation of vitamin and mineral metabolism: the level of essential elements was decreased and the level of toxic elements was increased. Comorbid biliary dyskinesia in adolescents with diffuse nontoxic goiter was accompanied by a disbalance of vitamins. The changes found in micronutrients have sex differences.

Defining Biliary Hyperkinesia and the Role of Cholecystectomy.

BACKGROUND: Functional gallbladder disorder is most commonly defined by biliary colic and low ejection fraction (EF) on cholescintigraphy. Biliary hyperkinesia is a controversial type of functional gallbladder disorder, and its definition and the role of cholecystectomy in treating functional gallbladder disorder remains unclear. STUDY DESIGN: We conducted a retrospective review of patients who underwent cholecystokinin-stimulated cholescintigraphy and cholecystectomy at 3 Mayo Clinic sites between 2007 and 2020. Eligible patients were 18 years or older, presented with symptoms of biliary disease, had an EF greater than 50%, underwent cholecystectomy, and had no evidence of acute cholecystitis or cholelithiasis on imaging. We used receiver operating characteristics curve analysis to identify the optimal cutoff value that predicted symptom resolution within 30 days of cholecystectomy. RESULTS: A total of 2,929 cholecystokinin-stimulated cholescintigraphy scans were performed during the study period; the average EF was 67.5% and the median EF was 77%. Analyzing those with EFs greater than or equal to 50% yielded 1,596 patients with 141 (8.8%) going on to have cholecystectomy. No significant differences were found in age, sex, BMI, final pathology between patients with and without pain resolution. Using a cutoff EF of 81% was significantly associated with pain resolution after cholecystectomy (78.2% for EF greater than or equal to 81% vs 60.0% for EF less than 81%, p = 0.03). Chronic cholecystitis was found in 61.7% of the patients on final pathology. CONCLUSIONS: We determined that an EF cutoff of 81% is a reasonable upper limit of normal gallbladder EF. Patients with biliary symptoms and an EF greater than 81% but no evidence of biliary disease on ultrasound or scintigraphy can be classified as having biliary hyperkinesia. Based on our findings, we recommend cholecystectomy for this patient population.

Use of endoscopic gallbladder stenting and biliary scintigraphy for diagnosis of gallbladder dyskinesia: a case report.

A 40-year-old woman visited our hospital with a several-year history of right hypochondriac pain and vomiting after eating. She had been treated for functional dyspepsia, with no improvement in her symptoms. No gallstones were detected on imaging tests, but papillary insufficiency or dyskinesia of the gallbladder was suspected and biliary scintigraphy was performed. Biliary scintigraphy showed delayed excretion of radionuclides from the gallbladder and bile ducts into the duodenum. We initially suspected papillary dysfunction and performed endoscopic sphincterotomy, but there was no improvement in her symptoms. Biliary scintigraphy also showed delayed excretion of radionuclides, especially stagnation of radionuclides in the gallbladder. We suspected gallbladder dyskinesia and performed endoscopic gallbladder stenting, after which her symptoms disappeared and biliary scintigraphy showed improved excretion of radionuclides into the duodenum. Endoscopic gallbladder stenting may be useful for the diagnosis of gallbladder dyskinesia and for determining the efficacy of cholecystectomy.

Optimum utilization of cholecystokinin cholescintigraphy (CCK-HIDA) in clinical practice: an evidence based review.

Laparoscopic cholecystectomy remains one of the most commonly performed operations in the United States. Of the cholecystectomies performed, approximately 30% are carried out for a diagnosis of gallbladder dyskinesia, for which diagnosis is based on a reduced gallbladder ejection fraction as determined by a sincalide (cholecystokinin) stimulated hepatobiliary iminodiacetic scan (CCK-HIDA). Despite the widespread acceptance of this practice standardization of the test methodology and high quality data indicating efficacy of cholecystectomy in the treatment of this condition are lacking. This manuscript reviews this problem in detail based on the current available literature.

Is biliary scintigraphy a reliable diagnostic tool for biliary dyskinesia in children?

BACKGROUND AND AIM: The role of hepatobiliary scintiscan (HIDA) in children suspected to be having functional biliary tract disease has not been studied. We evaluated HIDA scan results as long-term prognostic indicators for biliary dyskinesia with or without intervention. METHODS: Children who had HIDA scan for chronic abdominal pain, nausea, or vomiting were included. These children had inconclusive gastrointestinal diagnostic workup. HIDA scan was performed according to a standardized protocol. Clinical data were collected by retrospective chart review. A telephonic survey was done 5 years after the initial HIDA scan to document long-term outcome. RESULTS: Forty-two of 61 children had abnormal HIDA scan. There was no difference between children with normal and abnormal HIDA results in clinical presentations, short-term (85.7% and 84.2%) and long-term (64.9% and 60%) outcomes. Twenty-seven of the 42 children with abnormal scan results underwent interventions (21 cholecystectomy only, 4 cholecystectomy followed by sphincter of Oddi sphincterotomy, and 2 sphincterotomy only). After intervention, children with abnormal HIDA scan had better short-term prognosis (88.9% and 54.5%), but their long-term prognosis (52.2% and 85.7%) was worse than those without intervention. No clinical prognostic factor could be identified. CONCLUSIONS: HIDA scan result is not a good prognostic indicator in children with suspected biliary dyskinesia. Caution should be exercised while using HIDA scan for selecting patients for surgical intervention. Focused prospective studies are needed to define biliary dyskinesia in children.

Ultrasound evaluation of gallbladder dyskinesia: comparison of scintigraphy and dynamic 3D and 4D ultrasound techniques.

OBJECTIVE: The purpose of this study was to determine the efficacy of 3D and 4D ultrasound in correlation with hepatoiminodiacetic acid (HIDA) scanning for calculating gallbladder ejection fraction (EF). SUBJECTS AND METHODS: A prospective study was conducted with 40 adult patients with suspected gallbladder dyskinesia. Cholecystokinin-provoked (99m)Tc-HIDA scintigraphy was performed, and concurrent 3D and 4D ultrasound images of the gallbladder were obtained before cholecystokinin infusion and 20, 30, and 40 minutes after infusion. The EF values calculated from the ultrasound images and HIDA scan were compared. RESULTS: The gallbladder EF values (mean ± standard error of the mean) calculated 20 minutes after cholecystokinin infusion from HIDA scans and 3D and 4D ultrasound images were 54.1% ± 5.0%, 58.9% ± 6.3%, and 62.8% ± 5.5%. Thirty minutes after infusion the EF values were 56.3% ± 4.7%, 56.9% ± 5.7%, and 59.1% ± 4.6%. The numbers of patients with an EF less than 50% were 14, 12, and 13, and the numbers with an EF less than 35% were 10, seven, and eight. For the patients with an EF less than 50%, the kappa agreement between HIDA scanning and 3D ultrasound was 0.89 (95% CI, 0.73-1.00), between HIDA scanning and 4D ultrasound was 0.83 (95% CI, 0.65-1.00), and between 3D and 4D ultrasound was 0.83 (95% CI, 0.64-1.00). CONCLUSION: Both 3D and 4D ultrasound techniques correlate well with HIDA scanning for calculating gallbladder EF in patients with suspected biliary dyskinesia.

Optimal Management of the Hyperkinetic Gallbladder: A Comparison of Outcomes Between Operative and Nonoperative Approaches.

BACKGROUND: A hyperkinetic gallbladder is defined as a hepatobiliary iminodiacetic acid (HIDA) scan ejection fraction (EF) of >80%. This condition is poorly described, and there is no current consensus on optimal management. The intent of this study was to determine if cholecystectomy improves symptoms in patients with a hyperkinetic gallbladder when compared to those managed nonoperatively and if there were variables predictive of symptom improvement with or without cholecystectomy. MATERIALS AND METHODS: This retrospective study included patients from 3 academic hospitals in the Atlanta metro area between the years 2006 and 2018. All patients with an EF >80% were included. Following voluntary exclusion patients were contacted by phone. Each patient was administered a questionnaire regarding their surgical history, medical management, and current symptom profile via Otago score. Institutional Institutional Review Board approval was obtained. RESULTS: 4785 HIDA scans were performed, and 194 reported an EF >80% (incidence 15.7%). 96% of these scans were reported as normal by the radiologist. 68 patients were able to be contacted by phone and completed the questionnaire. 18 patients underwent cholecystectomy, and 89% reported that their symptoms attributed to gallbladder disease were no longer present. 50 patients did not undergo cholecystectomy, and alternate diagnoses, medication prescriptions, diet modification, emergency department visits, and Otago score were higher in this cohort. DISCUSSION: Patients who undergo cholecystectomy for a diagnosis of hyperkinetic gallbladder, on average, report improvement in symptoms when compared to patients managed nonoperatively. This study supports the practice of reporting and managing hyperkinetic gallbladders as a pathologic entity.

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.

What is the role of the cholecystokinin stimulated HIDA scan in evaluating abdominal pain in children?

PURPOSE: Cholecystokinin stimulated HIDA (CCK-HIDA) has been used to identify patients with biliary dyskinesia and select patients likely to benefit from cholecystectomy. The appropriate use of this study in children remains controversial and this study aims to better understand the utility of this test. METHODS: Children who underwent a CCK-HIDA for evaluation of abdominal pain over a 15-year period were included, after excluding infants and patient's s/p liver transplant. Relevant clinical and outcomes data were abstracted and analyzed. RESULTS: 124 patients met inclusion criteria. Mean age was 14.5 ± 2.6 years, Mean BMI was 27.9 ± 9.9 and 96 (77.4%) presented with right upper quadrant or epigastric pain. The mean ejection fraction (EF) was 58.5 ± 31.8%, with 37 (29.8%) < 35% EF. Using receiver operating curve analysis no specific EF threshold value predictive of resolution of symptoms was identified (AUC 0.510; p = 0.94). Using EF <35% and >35% and <20% and >20%, no association was noted with partial/complete resolution of symptoms. On multivariate regression analysis neither EF nor pain reproduction with CCK administration were independently associated with resolution of symptoms. CONCLUSIONS: These data suggest that the CCK-HIDA scan is a poor predictor of benefit from cholecystectomy. Prospective large studies would help in identifying better criterion for patient selection, especially with the trend of increasing surgery for functional gallbladder disorders. TYPE OF STUDY: Case cohort. LEVEL OF EVIDENCE: IV.

[The occurrence of gallbladder contractility disorders in children with some diseases presenting as abdominal pain]. / Ocena zaburzen kurczliwosci pecherzyka z6lciowego w róznych stanach chorobowych, przebiegajacych z bólami brzucha u dzieci.

UNLABELLED: Gallbladder dyskinesia is not mentioned among current (ROME III) classification of the functional gastrointestinal disorders in children. However both own clinical experience and a few published data spike for the appearance these disturbances also in the developmental age. AIM OF THIS STUDY: Ultrasound (US) evaluation of gallbladder (GB) contractility in children sick from some diseases presenting as abdominal ailments. MATERIAL AND METHODS: 113 children aged 2-17 yr. (among them 78 with different diseases expressed as upper/middle recurrent abdominal pain and 35 healthy patients, forming the control group) were examined by US (Toshiba SSA-270 and GE Logiq 500 Pro device) to establish their GB activity. Using US, length, width and height of GB were measured, before and after standard fatty meal stimulation. Collected data enabled to count primary volume of GB and to evaluate of its changes, depending on time, which passed since the standard fatty meal, provoking GB activity, has been eaten. The spectrum of co-existing diseases with GB activity disorders was analyzed. RESULTS: Of 78 examined children with abdominal pains in 67 (86%) GB activity disorders were observed. The average GB volume value was decreased about 36%, in the examined group, whereas the change averaged about 71% in the control study (p < 0.01). From among the 78 of investigated children in 8 (10%) a total lack of GB reaction on the standard meal was stated. In healthy control group only in 4 children (11%) minimal disorders of GB activity were observed (p < 0.001) and none of healthy children has presented GB akinesia. After a year follows-up since the successful basic disease treatment has been applied, ultrasound GB activity examination showed generally improvement, except the cases permanently being obese. From among co-existed diseases most often obesity and other functional disorders as Helicobacter pylori related dyspepsia, constipation and GERD, as well as parasitic diseases and food allergy were notified. CONCLUSIONS: Gallbladder activity disorders might be the origin of abdominal pains during the course of some other diseases and might concern various age including younger children even in kindergarten age. In children, weaken or abolished GB contractility most often co-exists with obesity, many other alimentary functional alimentary disorders, parasitosis and food allergy.

Laparoscopic cholecystectomy for ultrasound normal gallbladders: Should we forego hepatobiliary iminodiacetic acid scans?

INTRODUCTION: Hepatobiliary iminodiacetic acid (HIDA)-radionuclear scans are used to diagnose biliary dyskinesia, the treatment for which is a laparoscopic cholecystectomy (LC). However, the predictive value of the HIDA scan for LC candidacy is debated. CASE: A physical, ultrasound, and blood test for a 53-year-old woman with biliary dyskinesia-like symptoms were normal, contradicting a textbook history. A HIDA-scan was ordered but the results suggested she was not eligible for a LC. The patient insisted on receiving the procedure and gave informed consent to undergo an elective LC. RESULTS: Six-weeks post-surgery, the patient's symptoms had ceased besides one short episode of abdominal pain. CONCLUSION: A LC relieved the patient's symptoms, suggesting that negative HIDA-scans can mislead correct decisions to perform a LC. Surgeons who receive inconclusive HIDA scan results should consult their patients, and when necessary and agreed-upon, take an informed risk together in an attempt to improve the patient's quality of life.

Introduction: La scintigraphie hépatobiliaire avec acide iminodiacétique (HIDA) radionucléaire sert au diagnostic de dyskinésie biliaire, qui est traitée par cholécystectomie par laparoscopie. La valeur prédictive de l'HIDA pour identifier les candidats à la cholécystectomie par laparoscopie fait cependant l'objet d'un débat. Cas: L'examen physique, l'échographie et les analyses sanguines d'une femme de 53 ans qui présentait des symptômes évoquant la dyskinésie étaient normaux, ce qui contredisait l'anamnèse modèle. Une scintigraphie HIDA a été réalisée, mais les résultats ont laissé croire que la patiente était inadmissible à la cholécystectomie par laparoscopie. La patiente a insisté pour subir l'intervention et a donné son consentement éclairé pour subir une cholécystectomie par laparoscopie non urgente. Résultats: Six semaines après l'intervention, les symptômes de la patiente étaient disparus, à l'exception d'un épisode de douleur abdominale. Conclusion: La cholécystectomie par laparoscopie a soulagé les symptômes de la patiente, ce qui laisse croire que la scintigraphie HIDA négative peut entraîner des erreurs de décision pour réaliser une cholécystectomie par laparoscopie. Les chirurgiens qui reçoivent des résultats inconcluants à la scintigraphie HIDA doivent consulter leurs patients, et lorsque nécessaire et entendu, prendre ensemble un risque éclairé pour tenter d'améliorer la qualité de vie des patients. Mots-clés: Dyskinésie biliaire, scintigraphie HIDA, cholécystite alithiasique, cholécystite chronique sans lithiases, dysfonctionnement biliaire, vésicules biliaires symptomatiques échographie normale.

Laparoscopic cholecystectomy for biliary dyskinesia in children: report of 100 cases from a single institution.

Laparoscopic cholecystectomy (LC) is increasingly performed in the pediatric population. Biliary dyskinesia (BD) is largely responsible for this increase and is presently the most common indication for LC in this age group. In our institution the diagnosis of BD is made in patients with biliary symptoms, absence of biliary stones, and an ejection fraction < 35 per cent on hydroxy iminoadiacetic acid (HIDA) scan. We reviewed our experience of 100 children with BD that underwent LC. Data that was prospectively collected and entered into electronic medical records by gastroenterologists, primary care physicians, and pediatric surgeons was reviewed and analyzed. Patients were symptomatic for an average of 15 months before undergoing surgery. Seventy-seven per cent reported resolution of symptoms from 6 months to 5 years following LC, whereas the rest complained of persistent symptomatology. When the two groups were compared, patients with persistent symptoms were more likely to be female and to have longer symptom duration. An ejection fraction < 35 per cent reliably predicts successful outcome of LC in patients with BD. The diagnosis of BD should be entertained early in the differential of functional abdominal pain in children and referred to Pediatric Surgery when its presence is confirmed.

Sonographic evaluation of gallbladder contractility in patients with spinal cord injury.

PURPOSE: To determine gallbladder volume with sonography during fasting and in response to a fatty meal in patients with spinal cord injuries (SCIs) and compare the results with those obtained in healthy controls. METHOD: Forty-three patients with SCI and 40 healthy volunteers without clinical evidence of gallbladder disease underwent sonography before and 30 and 60 minutes after the ingestion of a standard fatty meal. The gallbladder fasting volume, resting volume, and gallbladder contractility were calculated, and the results were compared. Correlation between gallbladder contractility and level of lesion, time since injury, use of oxybutynin, and body mass index (BMI) was also assessed. RESULTS: The mean ejection fraction was significantly lower in the patients with SCIs (40%) compared with healthy controls (63%) (p < 0.001). Gallbladder mean residual volume 60 minutes after ingestion of the fatty meal was lower in the control group (p < 0.001). CONCLUSION: Gallbladder contractility is impaired in patients with SCI, which may predispose these patients to gallstone formation. There was no correlation between gallbladder contractility and level of the lesion, time since injury, use of oxybutynin, or BMI.