From the Guidelines
Biliary dyskinesia is a functional disorder of the gallbladder characterized by impaired gallbladder contraction and bile flow without gallstones, and the most effective treatment for patients with persistent symptoms and confirmed low ejection fraction is laparoscopic cholecystectomy, providing symptom relief in 70-90% of properly selected patients. Patients typically experience right upper quadrant pain, nausea, and bloating after eating fatty foods. Diagnosis involves a hepatobiliary iminodiacetic acid (HIDA) scan with calculation of the gallbladder ejection fraction, with values below 35-40% considered diagnostic 1.
Key Considerations
- The condition results from dysfunction of the sphincter of Oddi or abnormal gallbladder motility, often related to hormonal factors, autonomic nervous system dysfunction, or inflammatory processes.
- Treatment often begins with dietary modifications including reduced fat intake and small, frequent meals.
- Medical management may include smooth muscle relaxants like hyoscyamine (0.125-0.25mg three times daily), prokinetics such as metoclopramide (5-10mg before meals), or ursodeoxycholic acid (8-10mg/kg/day) 1.
- Patients should be evaluated for other conditions with similar symptoms, including irritable bowel syndrome, functional dyspepsia, and gastroesophageal reflux disease, before proceeding with invasive treatments.
Diagnostic Approach
- A hepatobiliary iminodiacetic acid (HIDA) scan is used to calculate the gallbladder ejection fraction.
- Values below 35-40% are considered diagnostic of biliary dyskinesia 1.
- The scan helps to assess the functional status of the gallbladder and biliary tract.
Treatment Options
- Laparoscopic cholecystectomy is the definitive treatment for patients with persistent symptoms and confirmed low ejection fraction, providing symptom relief in 70-90% of properly selected patients.
- Dietary modifications and medical management are used as initial treatments, but may not provide adequate symptom relief in all patients 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 a reduced gallbladder ejection fraction on a cholecystokinin-cholescintigraphic scan 2, 3.
- The diagnosis of biliary dyskinesia is made if the gallbladder ejection fraction is less than 35% to 40% using cholecystokinin cholescintigraphy 4.
Treatment of Biliary Dyskinesia
- Cholecystectomy remains a commonly applied treatment for biliary dyskinesia, despite a lack of high-quality evidence supporting the practice 2, 3.
- Laparoscopic cholecystectomy is a common treatment for biliary dyskinesia, but the majority of studies on the topic are retrospective, with wide variations in inclusion criteria and definition of biliary pain 3.
- The use of cholecystectomy for adult biliary dyskinesia is reasonable based on the available data, but insufficient data exist regarding laparoscopic cholecystectomy for pediatric dyskinesia and the hyperkinetic gallbladder population 3.
Controversies and Knowledge Gaps
- There is a lack of high-quality evidence supporting the practice of cholecystectomy for biliary dyskinesia 2, 3.
- Diagnostic criteria are less stringently applied, which may contribute to ongoing resource utilization 5.
- 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.