Initial Treatment for Biliary Dyskinesia
Cholecystectomy is the first-line treatment for biliary dyskinesia, with laparoscopic cholecystectomy showing symptom resolution in 88-94% of patients with abnormal gallbladder ejection fraction. 1, 2, 3
Diagnostic Criteria and Evaluation
- Biliary dyskinesia is a functional gallbladder disorder characterized by altered gallbladder motility, presenting with biliary symptoms without imaging evidence of gallstones or other structural pathology 1
- Diagnosis is primarily made by demonstration of abnormal gallbladder emptying on hepatic iminodiacetic acid scan with cholecystokinin administration (HIDA-CCK) 1, 2
- An ejection fraction (EF) <40% on CCK-HIDA scan is considered diagnostic of biliary dyskinesia 4
- Some patients may have normal ejection fraction (35-80%) but experience pain with CCK injection, which is also predictive of symptom resolution after cholecystectomy 5
Treatment Algorithm
First-line Treatment:
- Laparoscopic cholecystectomy is the treatment of choice for patients with confirmed biliary dyskinesia 1, 2, 3
- Patients with an EF <50% on CCK-HIDA scan have a 94-98% improvement or resolution of symptoms after cholecystectomy 2, 4
- Even patients with normal EF but pain reproduction during CCK administration show 83.4% improvement with cholecystectomy 2
Patient Selection:
- Best candidates for surgery include:
- Patients with typical biliary symptoms (episodic right upper quadrant or epigastric pain) 1, 4
- Abnormal gallbladder ejection fraction <40% on CCK-HIDA scan 4
- Normal ultrasound findings (absence of gallstones or other structural abnormalities) 1, 2
- Pain reproduction during CCK administration, even with normal EF 5
Expected Outcomes
- Long-term follow-up studies demonstrate symptom response in 88% of patients at a mean follow-up of 65 months 3
- Pathology specimens from patients with biliary dyskinesia commonly show chronic cholecystitis (84%), normal findings (10%), or cholesterolosis (7%) 1
- All patients in recent studies experienced resolution of symptoms postoperatively 1
Special Considerations
- Patients with biliary dyskinesia tend to be younger and have lower BMI than those with cholelithiasis 1
- The condition occurs more commonly in women (92% in recent studies) 1
- Patients requiring fewer preoperative diagnostic procedures (mean 1.56) tend to have better outcomes than those requiring multiple diagnostic tests (mean 2.5) 3
Clinical Pearls and Pitfalls
- CCK-HIDA scans should be employed early in the evaluation of biliary colic with normal ultrasound findings 2
- When test results show abnormal ejection fraction, cholecystectomy should be performed promptly, as results approach those of cholecystectomy for stone disease (>90% cured/improved) 2
- Early surgical intervention may avoid extensive and expensive medical testing 2
- Normokinetic biliary dyskinesia (normal EF with pain during CCK injection) should not be overlooked, as these patients also benefit from cholecystectomy 5