From the Guidelines
Biliary dyskinesia should be diagnosed using a hepatobiliary iminodiacetic acid (HIDA) scan with cholecystokinin stimulation, with a normal gallbladder ejection fraction defined as ≥38% 1. This condition is a functional disorder of the gallbladder characterized by impaired gallbladder contraction and bile flow without gallstones. Patients typically experience right upper quadrant pain, nausea, and bloating after meals, especially fatty ones.
Key Points
- Diagnosis involves a HIDA scan with cholecystokinin stimulation, showing a gallbladder ejection fraction below 35-40%
- Initial treatment includes dietary modifications (reducing fat intake), weight management, and medications like ursodeoxycholic acid to improve bile flow or antispasmodics such as dicyclomine (10-20mg three times daily) to relieve pain
- For patients with persistent symptoms and confirmed low ejection fraction, laparoscopic cholecystectomy is often recommended and provides symptom relief in 70-80% of properly selected patients. The condition results from abnormal gallbladder motility due to dysfunction of the smooth muscle or nerves controlling gallbladder contraction, possibly related to cholecystokinin receptor abnormalities or autonomic nervous system dysfunction.
Treatment Considerations
- Patients should be aware that symptoms may persist after surgery in some cases, particularly if other functional gastrointestinal disorders are present
- The management of biliary dyskinesia should prioritize reducing symptoms and improving quality of life, with surgical options considered for those with severe or refractory symptoms 1.
From the Research
Definition and Diagnosis of Biliary Dyskinesia
- Biliary dyskinesia 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 2, 3.
- The diagnosis of biliary dyskinesia is based on the presence of biliary pain, a sonographically normal gallbladder, and a reduced gallbladder ejection fraction on cholecystokinin-cholescintigraphy (CCK-HIDA) scan 3.
Treatment Options for Biliary Dyskinesia
- Cholecystectomy remains a commonly applied treatment for biliary dyskinesia, despite a lack of high-quality evidence supporting the practice 2, 3.
- Nifedipine has been observed to relax the sphincter of Oddi and to enhance biliary drainage, especially in patients suffering from sphincter of Oddi dyskinesia, and may be tried for reducing the number of painful days and need for analgesics in patients with this disorder 4.
- Endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy may be considered as diagnostic and therapeutic options before opting for cholecystectomy in patients with reduced gallbladder ejection fraction and normal lab results 5.
Controversies and Knowledge Gaps in Biliary Dyskinesia
- There is a lack of high-quality evidence supporting the use of cholecystectomy for biliary dyskinesia, and the majority of studies on the topic are retrospective with wide variations in inclusion criteria and definition of biliary pain 3.
- Randomized trials addressing the knowledge gaps in biliary dyskinesia are needed, but have been difficult to conduct due to strong clinician and patient bias toward surgery and the lack of a criterion-standard nonsurgical treatment for the control arm 3.
- Large-scale prospective studies are needed to address the knowledge gaps surrounding this controversial diagnosis and to develop stronger, more evidence-based practice guidelines for treating biliary dyskinesia 2, 3.