From the Guidelines
Biliary dyskinesia should be diagnosed and treated based on symptoms and gallbladder ejection fraction measurement via HIDA scan, with a cut-off value of below 35-40% considered diagnostic, as recommended by the 2011 consensus recommendations of an interdisciplinary panel 1. The diagnosis of biliary dyskinesia involves a combination of clinical presentation and diagnostic testing. Patients typically experience right upper quadrant pain, nausea, and bloating after meals, especially fatty ones.
- The gallbladder ejection fraction measurement via HIDA scan is a key diagnostic tool, with values below 35-40% considered diagnostic.
- Initial treatment includes dietary modifications, such as reducing fat intake and eating smaller, more frequent meals.
- Medications like ursodeoxycholic acid or antispasmodics such as dicyclomine may also be used to manage symptoms. The pathogenesis of functional biliary pain, including biliary dyskinesia, remains poorly understood, but it is thought to occur as a result of increased gallbladder pressure caused by an abnormal pattern of gallbladder contractions in the setting of either structural or functional outflow obstruction, as discussed in the 2011 study 1.
- Theories proposed include gallbladder hypomotility, partial structural or functional gallbladder outlet obstruction, discoordination between gallbladder contraction and sphincter of Oddi relaxation, and visceral hypersensitivity.
- For patients with severe symptoms and confirmed low ejection fraction who don't respond to conservative measures, laparoscopic cholecystectomy may be recommended, with a reported effectiveness of 70-90% in properly selected patients.
From the Research
Definition and Diagnosis of Biliary Dyskinesia
- 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 2.
- 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 3.
- Diagnostic adjuncts such as hepatobiliary scintigraphy and sphincter of Oddi manometry exist, although these results are supportive and not necessarily diagnostic for biliary dyskinesia 3.
Treatment and Management of Biliary Dyskinesia
- Cholecystectomy remains a commonly applied treatment for BD, despite a lack of high-quality evidence supporting the practice 2.
- Surgical intervention is most successful when selecting for patients with typical biliary pain 3.
- Ursodeoxycholic acid (UDCA) has been shown to have a significantly superior effect compared with placebo in treating dyspeptic symptoms and pain in cholelithiasis and biliary dyskinesia 4.
Challenges and Controversies in Biliary Dyskinesia
- A significant number of patients undergo cholecystectomy for biliary dyskinesia, even though they do not meet currently accepted diagnostic criteria 5.
- Healthcare resource utilization drops within the first year after surgery, but ER visits and hospitalizations remain common, suggesting a more limited benefit of surgical approaches in these patients 5.
- Patients not meeting consensus criteria for the diagnosis of biliary dyskinesia are more likely to use opioids and have ER visits prior to and after cholecystectomy 5.