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. Biliary dyskinesia is a functional disorder of the gallbladder characterized by impaired gallbladder contraction and bile flow without gallstones or structural abnormalities. Patients typically experience right upper quadrant pain, nausea, and bloating after meals, especially fatty foods. Some key points to consider in the diagnosis and management of biliary dyskinesia include:
- Diagnosis involves a HIDA scan with cholecystokinin stimulation, showing a gallbladder ejection fraction below 35-40%
- Initial treatment includes dietary modifications (reducing fat intake, eating smaller, more frequent meals) and medications like ursodeoxycholic acid or antispasmodics such as hyoscyamine
- For persistent symptoms despite conservative management, laparoscopic cholecystectomy is often recommended, with success rates of 70-90% The condition results from abnormal gallbladder motility due to dysfunction of the sphincter of Oddi or altered cholecystokinin sensitivity. Patients should be evaluated for other conditions with similar symptoms, including irritable bowel syndrome and functional dyspepsia, as these may coexist or mimic biliary dyskinesia. It's worth noting that the study from 1 provides the most recent and highest quality guidance on the diagnosis of biliary dyskinesia, and should be prioritized in clinical decision-making. In contrast, the study from 1 focuses on the management of common bile duct stones, and is not directly relevant to the diagnosis and management of biliary dyskinesia.
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.