From the Guidelines
Biliary dyskinesia should be diagnosed using a standardized cholecystokinin-cholescintigraphy (CCK-CS) protocol, with a normal gallbladder ejection fraction defined as ≥38%, as recommended by a consensus panel 1.
Diagnosis and Treatment
Biliary dyskinesia is a functional disorder of the gallbladder characterized by impaired gallbladder contraction and bile flow, causing symptoms similar to gallstones despite the absence of stones. Diagnosis typically requires symptoms of biliary pain (right upper quadrant or epigastric pain, often after meals), normal liver enzymes, absence of gallstones on ultrasound, and a gallbladder ejection fraction below 35-40% on a HIDA scan.
- Treatment options include lifestyle modifications (low-fat diet, small frequent meals), medications (antispasmodics like dicyclomine 10-20mg three times daily, or prokinetics), and surgical intervention with laparoscopic cholecystectomy for severe cases.
- The condition likely results from abnormal gallbladder motility due to dysfunction of the sphincter of Oddi, hormonal imbalances, or autonomic nervous system irregularities.
Management Approach
Patients should be evaluated for other gastrointestinal conditions like irritable bowel syndrome or functional dyspepsia, as these can coexist with biliary dyskinesia and may require separate management approaches.
- Surgery is generally recommended for patients with typical symptoms and abnormal HIDA scan results, with approximately 70-80% of patients experiencing symptom improvement post-cholecystectomy, although this is not directly supported by the provided evidence, the approach is based on general medical knowledge and the need to prioritize morbidity, mortality, and quality of life.
- The use of CCK-CS in the diagnosis of functional gallbladder disease, including biliary dyskinesia, is emphasized, with the need for a large, multicenter, prospective clinical trial to establish its utility 1.
- Updated guidelines on the management of common bile duct stones (CBDS) suggest that surgical extraction of CBDS at the same time as (laparoscopic) cholecystectomy offers the opportunity to definitively treat gallstone-related disease in a single-stage procedure, but this is more relevant to CBDS than biliary dyskinesia 1.
From the FDA Drug Label
It appears to have little inhibitory effect on synthesis and secretion into bile of endogenous bile acids, and does not appear to affect secretion of phospholipids into bile. The FDA drug label does not answer the question.
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 a reduced gallbladder ejection fraction on a cholecystokinin-cholescintigraphic scan 2, 3.
- The Rome IV Criteria establishes diagnostic criteria for functional gallbladder disorder (gallbladder dyskinesia and biliary hyperkinesia), functional biliary sphincter of Oddi disorder (biliary dyskinesia), and pancreatic sphincter of Oddi disorder 4.
- Diagnostic adjuncts such as hepatobiliary scintigraphy and sphincter of Oddi manometry exist, although these results are supportive and not necessarily diagnostic for biliary dyskinesia 4.
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 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 5.
- Surgical intervention is most successful when selecting for patients with typical biliary pain 4.
Controversies and Knowledge Gaps
- There is a lack of high-quality evidence supporting the practice of cholecystectomy for biliary dyskinesia, and most studies on the topic are retrospective with wide variations in inclusion criteria and definition of biliary pain 3.
- Randomized trials addressing these gaps are needed but have been difficult to conduct owing 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, either randomized trials or large prospectively followed cohort studies, are needed to address the knowledge gaps surrounding this controversial diagnosis 3.