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Biliary Dyskinesia

Biliary Dyskinesia is due to irregularity in the contraction of the gallbladder or the adjoining sphincter whcih result in accumulation of bile in the gall bladder.


Presentation

The common symptoms of biliary dyskinesia are:

  • Localized dull intermittent pain in the right upper hypochondrium, which can occur about 1-2 hours after eating a fatty meal or any stressful condition. This pain can also radiate to upper back and back of the shoulder more on the right side. Sometimes the only symptom may be a referred pain in the shoulders. This pain usually occurs due to some irregularity in the contraction of the gallbladder or in the functioning of the muscle sphincter. This is the most prominent and persistent symptom. This pain is typically biliary colic, but is not colicky. Most times the pain occurs at midnight, but this is not universal. Typically, the intense excruciating pain lasts for only 30-40 minutes and subsides slowly. One episode of pain usually lasts for about less than six hours.
  • Bad or bitter taste in mouth, usually when one gets up in the morning. This happens due to backward flow of bile from duodenum to stomach followed by esophagus. Dysfunction of esophageal sphincter normally occurs in biliary dyskinesia.
  • Other symptoms include nausea, vomiting, abdominal fullness and bloating. Nausea and vomiting usually result due to cholestasis, wherein there is stagnation of bile and it is unable to reach the duodenum from the liver. Constipation, diarrhea and reduced appetite may also occur.
  • Bad breath and bitter taste also occur as a result of reflux of bile and bile accumulation in the gall bladder.
Abdominal Pain
  • Presenting symptoms included abdominal pain (86%), fatty food intolerance (27%), emesis (13%), and diarrhea (13%). Mean duration of abdominal pain before operation was 11 /-19 months (range: 2 weeks-6 years).[ncbi.nlm.nih.gov]
  • Sixty-four children with chronic abdominal pain and no gallstones on ultrasound had an abnormal CCK-HIDA scan.[ncbi.nlm.nih.gov]
  • Abstract Biliary dyskinesia (BD) is a well-recognized cause of chronic abdominal pain in adults, but is less common in children.[ncbi.nlm.nih.gov]
  • BACKGROUND/PURPOSE: The authors reviewed their experience with a group of children with chronic abdominal pain, delayed gallbladder emptying, and no cholelithiasis.[ncbi.nlm.nih.gov]
  • Five children with normal biliary ultrasounds were evaluated between January 1990 and December 2000 for recurrent upper abdominal pain.[ncbi.nlm.nih.gov]
Fat Intolerance
  • Symptoms Of Biliary Dyskinesia gallbladder attacks in the absence of gallstones right upper abdominal pain after eating gas, bloating, burping, nausea, vomiting, fat intolerance and any or all other symptoms of gallbladder disease and colic Diagnosis[gallbladderattack.com]
  • Biliary colic is most commonly located in the right upper quadrant but can be found in the epigastrium or in the chest, 7 , 8 and it is often associated with abdominal bloating, nausea, dyspepsia, vomiting, and fat intolerance. 8 The differential diagnosis[doi.org]
  • Biliary colic is most commonly located in the right upper quadrant but can be found in the epigastrium or in the chest, 7, 8 and it is often associated with abdominal bloating, nausea, dyspepsia, vomiting, and fat intolerance. 8 The differential diagnosis[jaoa.org]
Biliary Colic
  • Surgical outcomes could be improved by careful histories distinguishing biliary colic from other complaints. Less reliance should be placed on the ejection fraction when the patient has biliary colic without another etiology of abdominal pain.[ncbi.nlm.nih.gov]
  • Diagnosis is made on the basis of symptoms of biliary colic in the absence of cholelithiasis and gallbladder inflammation.[ncbi.nlm.nih.gov]
  • Abstract The diagnosis and treatment of biliary dyskinesia, defined as symptoms of biliary colic in the absence of gallstones, remains controversial and has been the subject of several previous retrospective reviews.[ncbi.nlm.nih.gov]
  • All 11 patients (100%) had "classic" biliary colic and underwent cholecystectomy. The pathologic diagnosis was chronic cholecystitis in every patient.[ncbi.nlm.nih.gov]
  • Abstract Biliary colic in the absence of demonstrable stones--and, indeed, in the absence of a gallbladder--has long been mystifying. Evidence is growing for the existence of purely functional disease of the biliary system.[ncbi.nlm.nih.gov]
Papule
  • Within several minutes the girl developed a massive abdominal cutaneous eruption composed of hundreds of punctuate erythematous papules and macules, which persisted for 5 to 7 days.[ncbi.nlm.nih.gov]

Workup

Diagnosis of biliary dyskinesia is basically based on exclusion of other causes of biliary colic. Usually, after an episode of biliary pain, the physical examination is normal with slight upper abdominal tenderness due to the pain. Other than a mild tenderness, no other symptom is elicited on clinical examination.

  • Blood biochemistry: Usually most of the blood tests are normal including liver enzymes. Only during an acute exacerbation or acute episode of pain, levels of conjugated bilirubin and alkaline phosphatase may rise. This happens again due to stasis of bile in the ducts. Laboratory tests should be done to look out for any kind of diseases of the liver, pancreas or any kind of biliary obstruction.
  • Ultrasound and other imaging techniques Ultrasound is able to detect gallstones and is 95% accurate. Gallstones are a frequent cause of obstruction in the gallbladder and biliary dyskinesia and have similar symptoms. Once this has been excluded, other tests are done for determining the cause.
  • Secretin test: A hormone called secretin is injected intravenously which causes an increase in the bile secretion. After this is injected an ultrasound can be done to determine the cause which prevents the bile from leaving the gallbladder.
  • CCK-HIDA scan: Also known as cholescintigraphy, it is a very popular and accurate method used for diagnosis of biliary dyskinesia [2]. This method uses a radioactive isotope 99Tc to study and visualize the biliary tract and the gall bladder. This technique can also be used to calculate the ejection fraction which evaluates how rapidly the bile leaves the gall bladder and how much bile remains in the gallbladder during contraction. A reading of more than 40% of bile remaining indicates biliary dyskinesia. Many medications and medical conditions are also responsible for alterations in gallbladder emptying. This should be kept in mind prior to coming to conclusion. A reduced ejection fraction also indicates a risk for developing biliary dyskinesia. This tracer marker also helps visualize any gallstone, sludge or any other abnormality in the biliary tract and gallbladder. Many consider this test as a poor test to reach conclusion; hence it is important to reach a diagnosis only after a careful history is taken.
  • Sphincter of Oddi Dysfunction: This is test is done in order to differentiate biliary or pancreatic sphincter of Oddi dysfunction. This is done with the help of an endoscope which reaches the duodenum, followed by which a catheter is passed into the bile duct and pancreatic duct to study the pressure and therapeutic procedures such as sphincterotomy can be performed simultaneously. This therapeutic procedure helps reduce pressure as well as provide relief to patients with biliary dyskinesia.

Thus to come to a confirmatory diagnosis certain criteria should fulfilled known as Rome III criteria:

  1. Pain episodes should be longer than 30 minutes.
  2. Recurrent episodes at frequent duration.
  3. Pain should be intense enough to disrupt normal schedule.
  4. A gradually increasing pain.
  5. Pain not ameliorated by bowel movements, antacids or posture change.
  6. Elimination of other structural diseases.
  7. Supportive criteria such as nausea, vomiting, radiation of pain along with biliary pain.
  8. Normal blood and liver biochemistry.
Endoscopy Abnormal
  • Abnormalities found on MRCP can be further evaluated or treated by ERCP or surgery. Author(s) and Publication Date(s) Young Choi, MD, and William B.[patients.gi.org]

Treatment

Before starting the treatment, it is vital to understand the exact mechanism of biliary dyskinesia, whether the problem is the contraction of the gallbladder or in the sphincter of Oddi. General advice regarding diet should be given, as patients with biliary dyskinesia should have at least 4-5 meals per day. Fatty food should be avoided and loads of fruits and berries should be included in the diet. Food should be boiled and steamed.

Medications in the form of antispasmodics can be given to reduce the spasm of the sphincter which prevents reflux of bile and allows free flow of bile through the biliary tract and ducts. Antispasmodics should not be given to individuals with gastroesophageal reflux disease as it can worsen the condition. Choleretics can be given to stimulate the secretion of bile and prevent its concentration and absorption back into the gall bladder.

Surgery is the mainstay of treatment, wherein laparoscopic cholecystectomy is done [3]. This procedure is performed by making 3-4 incisions on the abdominal wall followed by removal of gallbladder with the help of a laparoscope. This is a minimal invasive procedure which provides relief to 90% of the cases. Another surgical option is sphincterotomy, wherein an incision is made on the sphincter of Oddi to help in the flow of bile. This also provides relief in the symptoms in about 80% of the cases [4]. Cholecystectomy still remains the best and most effective form of treatment for biliary dyskinesia.

Prognosis

The prognosis of biliary dyskinesia is usually not associated with this symptom complex, but rather with the method of treatment or invasive diagnostic techniques. Biliary dyskinesia usually does not progress into any serious condition.
The earlier this condition is detected and treated the better is the prognosis, if treated with cholecystectomy. Symptomatic relief is achieved with cholecystectomy, but complete resolution of symptoms is not achieved with surgery.

Etiology

The causative factors of this condition are not clear and biliary dyskinesia is a symptom complex rather than a disease itself. Often this motility disorderrequires cholecystectomy; hence it is also termed as post cholecystectomy syndrome. The symptom of biliary dyskinesia may also indicate other pathologies such as inflammation or gallstones, and even certain food stuffs can trigger this disorder. Chronic inflammation also can result in biliary dyskinesia. Recent studies indicate stress as a causative factor for biliary dyskinesia. Some dysfunction in dopamine receptors will result in gallbladder not receiving signals from the brain. Other risk factors include obesity, low roughage and fat diet, increased sugar intake, history of thyroid dysfunction, patients with irritable bowel syndrome, increased intake of alcohol and individuals with decreased gastric acid production. Differentiation should be made regarding failure of the biliary sphincter or the pancreatic sphincter [1].

Epidemiology

The exact prevalence is not known. The occurrence of functional biliary pain in normal ultrasound is 8% in men and 21% in women. The best epidemiological screening test for this functional disorder is ultrasound. Biliary dyskinesia affects females more than males, usually between the age group of 40-60 years. Nowadays, with the increasing use of laparoscopic surgery, biliary dyskinesia tops the list for indication of laparoscopic cholecystectomy in cases of functional gallbladder disease, ranging about 10-20% in adults. Though the cases of biliary dyskinesia post cholecystectomy are present, no evident documentation exists.

Sex distribution
Age distribution

Pathophysiology

The exact cause still remains unclear, but this condition arises due to an abnormality in the motility of the gall bladder. Biliary dyskinesia is regarded as a condition arising due to an abnormality in the movement of the bile. There are a number of factors responsible for the obstruction of the physiological transportation of bile from the gall bladder to the small intestine. If the sphincter of Oddi does not function optimally, it prevents the transportation of bile through the common bile duct to the duodenum. This results in stagnation of bile in the gall bladder leading to biliary dyskinesia. Any abnormality in production of bile or its traverse through the bile duct will result in biliary dyskinesia. Thus, these reasons cause a disruption in the normal physiological transport of bile to the small intestine resulting in changes in the metabolism of the body.

Prevention

Certain steps can be taken to prevent biliary dyskinesia such as:

  • Avoidance of fatty and greasy food. Boiled and steamed food should be taken.
  • Physical activity should be done and sedentary lifestyle should be avoided.
  • Stress can also trigger or aggravate biliary dyskinesia.
  • Periodic checkups of cholesterol and other important medical parameters.
  • Certain herbal remedies can be taken as supplements to improve bile secretion and flow such as artichokes, yarrow and dandelion.

Summary

Repetitive pain in the right upper abdomen can be a challenging symptom to be diagnosed by physicians, although this type of pain is common and termed as biliary colic. Biliary dyskinesia is a frequent term for a medical disorder known as acalculous cholecystopathy. This condition is diagnosed in cases with persistent right sided upper abdominal pains with the absence of gallstones, typically similar to biliary colic. This is a functional condition wherein the motility of the gallbladder is reduced. The condition is purely symptomatic with no known cause, more or less similar to the other metabolic disorders affecting the motility of the gastrointestinal tract. Thus, biliary dyskinesia is a motility disorder which indicates either abnormal functioning of the gallbladder or the Sphincter of Oddi which is located at the end of the common bile duct.

The gallbladder's primary function is to store the bile released by the liver. This bile further reaches the small intestine to help in the process of digestion. Thus, any obstruction in this pathway either through common bile duct or in the functioning of the gallbladder itself, results in biliary dyskinesia. Due to this abnormal functioning and motility, it leads to stagnation of bile in the gallbladder. Thus, this disorder is a symptom which indicates some underlying pathology leading to dyskinesia rather than a disease itself. Diagnosis of biliary dyskinesia is made after other causes of abdominal pain have been excluded.

The common choice of treatment is laparoscopic cholecystectomy, though the success is not sure. The exact etiology of this medical condition is not clearly understood.

Patient Information

Biliary dyskinesia is a common condition of the gall bladder wherein an individual usually complains of a dull aching pain in the right upper abdominal pain. This pain may be accompanied by nausea or vomiting. This condition usually affects females more than males and is a primary motility disorder of the gallbladder and its sphincter muscles. There is no known cause for this condition and a diagnosis is usually formed on the principle of exclusion. Absence of gallstones and sludge and other structural abnormality in the gallbladder and biliary tract usually indicate this condition. This condition is due to irregularity in the contraction of the gallbladder or the adjoining sphincter whcih result in accumulation of bile in the gall bladder. A complete examination and workup assist the physician to come to a diagnosis. Certain blood tests and scans will be required to exclude other causes with similar pain in the abdomen. Surgical removal of gall bladder is the preferred choice of treatment which provides relief to most of the cases. Certain dietary restrictions and exercise can help you prevent and control biliary dyskinesia.

References

Article

  1. Toouli J. Biliary Dyskinesia. Curr Treat Options Gastroenterol.August 2002; 5 (4): 285–291.
  2. Richmond BK, DiBaise J, Ziessman H. Utilization of Cholecystokinin Cholescintigraphy in Clinical Practice.J Am Coll Surg. 2013 Aug;217(2):317-23.
  3. Haricharan RN, Proklova LV, Aprahamian CJ, et al. Laparoscopic cholecystectomy for biliary dyskinesia in children provides durable symptom relief. J. Pediatr. Surg. June 2008;43 (6): 1060–1064.
  4. Mahid SS, Jafri NS, Brangers BC, Minor KS, Hornung CA, Galandiuk S. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. Feb 2009;144(2):180-7.

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Last updated: 2018-06-22 05:04