Use of a Fatty Meal Cholecystagogue Protocol in Hepatobiliary Scintigraphy for Chronic Functional Gallbladder Disease.

Chronic functional gallbladder disorder, characterized by biliary pain in the absence of structural pathology, poses a diagnostic challenge necessitating reliable cholecystagogues for accurate evaluation. However, recurrent shortages of synthetic cholecystokinin analogs have prompted the exploration of alternative agents. This paper describes the efficacy of Ensure Plus as a viable fatty meal substitute for hepatobiliary scintigraphy in assessing chronic functional gallbladder disorder. Through comparative studies, Ensure Plus demonstrates comparable diagnostic accuracy to cholecystokinin in similar patient populations. Furthermore, Ensure Plus demonstrates significant symptom improvement after cholecystectomy in patients with anomalous gallbladder ejection fractions. This paper offers a detailed protocol for the seamless integration of Ensure Plus into hepatobiliary scintigraphy, providing clinicians with a valuable tool to navigate cholecystokinin shortages while maintaining diagnostic precision in cases of chronic functional gallbladder disorder. The use of Ensure Plus not only addresses practical supply challenges but also underscores its potential as a cost-effective and clinically sound alternative in biliary diagnostics.

Is abnormal gallbladder ejection fraction hokum? Retrospective chart review of gallbladder ejection fraction and subsequent postoperative symptom relief, surgical pathology, and current literature review.

The purpose of this report is to investigate the clinical importance of increased or decreased gallbladder ejection fraction (GBEF) and ultrasound findings for biliary dyskinesia by evaluating postsurgical symptom relief and surgical pathology. Single institution electronic medical record review was prepared for patients who underwent hepatobiliary iminodiacetic acid (HIDA) scan with GBEF and cholecystectomy between January 2013 and March 2020. Relevant data included patient demographics, ultrasound results, surgical pathology, HIDA with GBEF results, and postoperative symptom relief at the time of follow-up. Student's t-test was also utilized for additional statistical analysis. A total of 67 patients underwent cholecystectomy within a 1-month period of time after HIDA with GBEF. Of these patients, 97% had findings consistent with chronic cholecystitis and 3% of the patients demonstrated both acute and chronic cholecystitis surgical pathology. Fifty-seven percent of the patients demonstrated a GBEF <38%, 30% had a GBEF >80%, and 13% had a GBEF 38%-80% with a postoperative symptom resolution around 82%, 77%, and 100%, respectively. GBEF alone may not be determinative regarding gallbladder pathology or postoperative symptom relief in patients that present with typical symptoms. Regarding dyskinetic gallbladders, elevated and decreased GBEF groups were not significantly different in terms of surgical pathology or symptom relief. These patients may benefit from being treated as a single group rather than as separate entities. Elevated and decreased GBEF groups demonstrated mostly normal ultrasound results that raised concern for the utility of ultrasound as a rule out test for gallbladder inflammation.

Gallbladder motility in children with celiac disease before and after gluten-free diet.

BACKGROUND: Gallbladder (GB) hypomotility has been reported in adults with celiac disease (CD), but there is no literature on GB dysfunction in children with CD. We aimed to study GB motility in children with CD, before and after a gluten-free diet (GFD), using ultrasonography (USG) and technetium-99 labeled mebrofenin hepatobiliary scintigraphy (HBS). METHODS: Children with newly diagnosed CD were enrolled and evaluated for GB ejection fraction (GBEF) using HBS and USG. Those with reduced GBEF on initial HBS were again evaluated after 6 months of strict GFD and the results were compared. RESULTS: Of the 50 children with CD (mean age 9±2.1 years, 54% boys), 16% (n=8) had a low GBEF at baseline (19±13%). These children had a significantly greater delay in diagnosis compared to those with normal GBEF (6.5±2.0 vs. 2.3±1.2 years, P<0.001). A significant improvement in GBEF was noted on HBS post GFD (74±12%1 vs. 9±13%, P<0.001). GBEF also improved significantly as assessed by USG parameters after GFD (P<0.001). The fasting GB volume decreased (5.7±1.4 vs. 10.2±2.6, P=0.002), with a significant improvement in percentage postprandial GB volume change (52±10.5% vs. 24±16.5%, P=0.007) compared to baseline pre-GFD values. Orocecal transit time was also increased in children with reduced GBEF. CONCLUSIONS: GB function is impaired in at least 16% of children with CD at diagnosis and is reversible with GFD. GB dysfunction is significantly associated with a delayed diagnosis and may be a part of general gastrointestinal dysmotility.

Biliary Dyskinesia: Current Perspectives and Future Directions.

Biliary dyskinesia (BD) is a disorder characterized by functional biliary pain, the absence of gallstones on ultrasound, and the finding of a reduced gallbladder ejection fraction on a cholecystokinin-cholescintigraphic scan. Cholecystectomy remains a commonly applied treatment for BD, despite a lack of high-quality evidence supporting the practice. The following article provides an overview of the current diagnostic strategies, treatment outcomes with both surgical and nonsurgical treatment, emerging considerations related to special populations, and suggestions for addressing the identified knowledge gaps, moving forward in an effort to develop stronger, more evidence-based practice guidelines for treating this poorly understood and poorly studied condition.

Improving Hepatobiliary Imaging as a Physiologic Test with Superior Clinical Outcomes.

This study aims at prospectively evaluating the difference in the effect of cholecystokinin (CCK) and half-and-half milk (HHM) administered in the same patient on gallbladder contractility and correlation with clinical outcomes. Upon gallbladder visualization during standard hepatobiliary imaging, 0.02 µg/kg of CCK was injected over 3 min, and additional 30 min of dynamic imaging was obtained. Patients with gallbladder ejection fraction (GBEF) <35% after CCK were administered 8 oz of HHM followed by 30 min of imaging. The GBEF was recalculated. The number of patients whom GBEF changed from below 35% (abnormal) after CCK to above 35% (normal) after HHM was recorded. Follow-up of the clinical outcome at 6 months was performed. Fifty patients with abnormal GBEF were prospectively included. The average GBEF after CCK was 14.7% ± 8.5% and after HHM was 30.7% ± 20.8%. The average increase in GBEF with HHM was 16.0% ± 22.2%. The GBEF changed from abnormal to normal in 17 patients (34%). The remaining 33 patients remained abnormal. Clinical outcomes at 6 months were available in 47 patients. Cholecystectomy was performed in 60% of patients with abnormal GBEF with CCK and HHM with resolution or improvement of pain. Two of 16 patients (12%) with abnormal GBEF after CCK but normal after HHM had cholecystectomies with pain improvement, while 8 out of these patients (50%) were diagnosed and treated with other disorders and improved. Hepatobiliary imaging with HHM stimulation is a superior physiologic test which can lower the number of unnecessary cholecystectomies and misdiagnoses as functional cholecystitis.

Self-reported Outcomes After Cholecystectomy for Pediatric Hyperkinetic Biliary Dyskinesia.

BACKGROUND: Biliary dyskinesia (BD) is a common indication for cholecystectomy in children. Current literature demonstrates an improvement in symptoms after cholecystectomy in most pediatric patients with an EF <35%; however, data supporting the efficacy of cholecystectomy for hyperkinetic BD (EF >65%) is sparse. We sought to determine whether children with hyperkinetic BD (HBD) had resolution of their symptoms after laparoscopic cholecystectomy at our institution. MATERIALS AND METHODS: We conducted a retrospective chart review of children who had undergone laparoscopic cholecystectomy for HBD at our institution between September 2010 and July 2015. Patients completed a phone survey about symptom resolution, whether they were happy to have undergone cholecystectomy, overall satisfaction on a 1-10 scale, and additional workup for those with ongoing pain. Analysis was performed using STATA statistical software with a P-value < 0.05 as statistically significant. RESULTS: Thirteen patients met inclusion criteria. Median gallbladder ejection fraction was 93% [IQR: 90, 97]. Median postoperative follow-up was 59 d [IQR: 25, 151] at which time 50% reported resolution of symptoms. Eight patients participated in the survey at a median follow-up of 45 mo [IQR: 40, 66]. Fifty percent reported ongoing abdominal pain. Frequency of pain varied among patients with pain, occurring from <1 time per week to a few times per day. Five patients (63%), including one patient with ongoing pain, were happy that their gallbladder had been removed and overall satisfaction rating was 5 on a scale of 1-10. CONCLUSIONS: Only half of children with HBD were asymptomatic at long-term follow-up. Cholecystectomy for HBD may or may not improve symptoms.

Effect of Albiglutide on Cholecystokinin-Induced Gallbladder Emptying in Healthy Individuals: A Randomized Crossover Study.

The glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) exenatide and lixisenatide reduce cholecystokinin (CCK)-induced gallbladder emptying in healthy subjects. It is unknown if all GLP-1 RAs share this effect; therefore, the effect of the GLP-1 RA albiglutide on gallbladder function was assessed. In this randomized, double-blind, 2-way crossover study, a single dose of subcutaneous albiglutide 50 mg or placebo was administered to 17 healthy subjects, and CCK-induced gallbladder contractility was measured by ultrasonography. CCK (0.003 µg/kg) was infused intravenously over 50 minutes on study day 4 (3 days after dosing, to coincide with albiglutide's expected time to maximum concentration). Gallbladder volume, ejection fraction, and the main pancreatic and common bile-duct diameters were measured before, during, and following CCK infusion. Gallbladder volume was significantly greater in the albiglutide vs placebo groups before, during, and after CCK infusion, and the mean difference from placebo increased numerically during CCK infusion. The area under the volume-effect curve was significantly greater with albiglutide (P = .029). Starting at the 30-minute CCK infusion time point, the gallbladder ejection fraction was significantly lower with albiglutide than placebo. Changes in pancreatic duct diameter and common bile-duct diameter were not significantly different between albiglutide and placebo. Similar incidences of adverse events were observed between the albiglutide and placebo treatment periods. No new albiglutide safety signals were detected, and no serious adverse events were reported. In conclusion, similar to other GLP-1 RAs, albiglutide decreased CCK-induced gallbladder emptying compared with placebo in healthy individuals. Clinical implications of the gallbladder effects are unclear at this time.

Decision-making patterns in managing children with suspected biliary dyskinesia.

AIM: To explore and to analyze the patterns in decision-making by pediatric gastroenterologists in managing a child with a suspected diagnosis of functional gallbladder disorder (FGBD). METHODS: The questionnaire survey included a case history with right upper quadrant pain and was sent to pediatric gastroenterologists worldwide via an internet list server called the PEDGI Bulletin Board. RESULTS: Differences in decision-making among respondents in managing this case were observed at each level of investigations and management. Cholecystokinin-scintigraphy scan (CCK-CS) was the most common investigation followed by an endoscopy. A proton pump inhibitor was most commonly prescribed treating the condition. The majority of respondents considered a referral for a surgical evaluation when CCK-CS showed a decreased gallbladder ejection fraction (GBEF) value with biliary-type pain during CCK injection. CONCLUSION: CCK infusion rate in CCK-CS-CS and GBEF cut-off limits were inconsistent throughout practices. The criteria for a referral to a surgeon were not uniform from one practitioner to another. A multidisciplinary team approach with pediatric gastroenterologists and surgeons is required guide the decision-making managing a child with suspected FGBD. ​.

Standardization of "In-House fatty meal" methodology for cholescintigraphy.

AIM: This study was aimed at standardizing the "In-House fatty meal" methodology in cholescintigraphy and to determine gall bladder ejection fraction (GBEF) with this standardized meal. MATERIALS AND METHODS: This is a prospective case-control study where 61 patients having right upper quadrant pain and postprandial bloating and 59 healthy volunteers were included. They underwent (99m)Tc-mebrofenin fatty meal cholescintigraphy following a standard protocol. Dynamic acquisitions over 120 min were done, with a fatty meal being given between 45- and 60-min. Gallbladder emptying kinetics was studied by assessing the time activity curves and calculation of GBEFs were made at 30-min, 45-min, and at 60-min and assessed. RESULTS: The GBEF at 30-min was 74.42% ± 8.26% (mean ± standard deviation), at 45-min was 82.61% ± 6.5%, and at 60-min was 89.37% ± 4.48% in the volunteer group. The lower limit of GBEF in volunteers at 30-min was 58%, 45-min was 69%, and at 60-min was 81%. Receiver operating characteristic (ROC) analysis showed that 30-min GBEF provided the best separation between healthy and diseased subjects with an area under curve of 0.952 (95% confidence interval = 0.914-0.989). The lower limit of GBEF at 30-min was 58%. CONCLUSIONS: An in-House standard fatty meal could be a reproducible alternative to cholecystokinin as it is well-tolerated. Based on ROC curve analysis, we propose that 30-min GBEF provides good separation between healthy and diseased people with this in-House fatty meal. Hence, dynamic acquisitions beyond 30-min postingestion of the fatty meal may not be warranted.

Liquid gastric emptying as an adjunct to hepatobiliary scintigraphy when oral corn oil is used as a cholecystagogue for determining gallbladder emptying.

UNLABELLED: During times of sincalide shortage, a fatty meal can be used to stimulate gallbladder contraction during hepatobiliary scintigraphy. However, if a patient has an abnormal gallbladder ejection fraction (GBEF), is the cause chronic cholecystitis or is it inadequate cholecystokinin stimulation due to poor gastric emptying? Hence, during the 2014 sincalide shortage, simultaneous liquid gastric emptying using (99m)Tc-sulfur colloid along with corn oil emulsion was initiated as routine practice in patients evaluated for GBEF. The objective of this study was to retrospectively assess the time course of gastric emptying in these patients, especially with regard to whether delayed gastric emptying may be a factor in some patients with a poor GBEF. METHODS: My institution's clinical imaging procedure during the 2014 sincalide shortage consisted of routine (99m)Tc-mebrofenin hepatobiliary scintigraphy followed by corn oil emulsion and (99m)Tc-sulfur colloid orally. Dynamic imaging with regions of interest encompassing the gallbladder and the stomach allowed determination of GBEF and gastric emptying. For this study, the imaging records for 53 consecutive patients undergoing this clinical procedure were reviewed. The time for half gastric emptying, along with percentage gastric emptying at the end of imaging, was evaluated in relationship to GBEF. RESULTS: Seventeen patients had a normal GBEF (74% ± 14%) and satisfactory gastric emptying (31 ± 21 min for half emptying, 75% ± 14% emptying at end of imaging); 17 patients had a normal GBEF (77% ± 17%) despite unsatisfactory gastric emptying (only 30% ± 14% emptying at end of imaging); 5 patients had an abnormal GBEF (19% ± 9%) and satisfactory gastric emptying (26 ± 19 min for half emptying, 82% ± 14% emptying at end of imaging), supporting a diagnosis of chronic cholecystitis; 11 patients had an abnormal GBEF (26% ± 9%) but also unsatisfactory gastric emptying (only 26% ± 13% emptying at end of imaging), which did offer additional support for a diagnosis of chronic cholecystitis; and 3 patients had a borderline GBEF (40% ± 2%) with satisfactory gastric emptying (59% ± 6% emptying at end of imaging). CONCLUSION: Simultaneous liquid gastric emptying can provide additional information in the interpretation of GBEF when a fatty meal is used as an oral cholecystagogue, especially to help differentiate chronic cholecystitis from inadequate cholecystokinin stimulation due to poor gastric emptying.

Impaired gallbladder motility in adults with newly detected type 2 diabetes and lack of reversibility after achieving euglycemia.

OBJECTIVE: The effects of hyperglycemia and normoglycemia on gallbladder emptying have not been studied in detail. This prospective case-control study was designed to investigate the gallbladder ejection fraction in patients with newly detected diabetes and to assess the impact of restoring normoglycemia on gallbladder ejection fraction in such patients. METHODS: (99m)Tc-mebrofenin scintigraphy was performed in 22 patients with newly detected type 2 diabetes for measurement of gallbladder ejection fraction. The scintigraphy was performed at the time of first presentation and again 6 months after control of diabetes (glycated hemoglobin [A1C] <7%). Also, gallbladder ejection fraction was measured in 20 age- and sex-matched controls without diabetes. RESULTS: Gallbladder ejection fraction was lower in patients with newly detected diabetes compared with controls (31.4%±5.9% vs. 70.7%±4.3%, p<0.001). Gallbladder ejection fraction did not improve after the treatment of diabetes mellitus (21.3%±5.7%, p=0.395). CONCLUSIONS: Gallbladder ejection fraction was markedly reduced in patients with newly detected diabetes compared to controls without diabetes. Control of diabetes and normalization of A1C did not reverse the motility defect.

Reproducibility of gallbladder ejection fraction measured by Fatty meal cholescintigraphy.

PURPOSE: There are conflicting data in the literature regarding the reproducibility of the gallbladder ejection fraction (GBEF) measured by fatty meal cholescintigraphy (CS). We aimed to test the reproducibility of GBEF measured by fatty meal CS. METHODS: Thirty-five subjects (25 healthy volunteers and 10 patients with chronic abdominal pain) underwent fatty meal CS twice in order to measure GBEF1 and GBEF2. The healthy volunteers underwent a repeat scan within 1-13 months from the first scan. The patients underwent a repeat scan within 1-4 years from the first scan and were not found to have chronic acalculous cholecystitis (CAC). Our standard fatty meal was composed of a 60-g Snickers chocolate bar and 200 ml full-fat yogurt. RESULTS: The mean ± SD values for GBEF1 and GBEF2 were 52 ± 17% and 52 ± 16%, respectively. There was a direct linear correlation between the values of GBEF1 and GBEF2 for the subjects, with a correlation coefficient of 0.509 (p = 0.002). Subgroup data analysis of the volunteer group showed that there was significant linear correlation between volunteer values of GBEF1 and GBEF2, with a correlation coefficient of 0.473 (p = 0.017). Subgroup data analysis of the non-CAC patient group showed no significant correlation between patient values of GBEF1 and GBEF2, likely due to limited sample size. CONCLUSIONS: This study showed that fatty meal CS is a reliable test in gallbladder motility evaluation and that GBEF measured by fatty meal CS is reproducible.