Biliary dyskinesia: a study of more than 200 patients and review of the literature

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. The diagnosis and treatment of biliary dyskinesia based on the CCK-HIDA scan, and the outcome with cholecystectomy for biliary dyskinesia, are reviewed. We add more than 200 cases of cholecystectomy for biliary dyskinesia, and compare our results with those of previous reports. We retrospectively reviewed 295 patients with biliary dyskinesia who underwent cholecystectomy at three military hospitals between 1988 and 1995. All patients had symptoms consistent with biliary colic and preoperative evaluations that revealed no evidence of cholelithiasis. Pathology specimens were reviewed for cholelithiasis and pathologic changes. Data were retrieved by chart review and clinic evaluation of new patients. Individual follow-up of each patient was attempted. Follow-up was achieved in 218 of the 295 patients for a rate of 74%. The mean duration of follow-up was 506 days with a range of 22 days to 6 years. Two hundred patients (92%) had CCK-HIDA scans with an ejection fraction (EF) <50%. Eighteen patients (8%) had an EF > 50% but did have reproduction of their symptoms with CCK injection. In the group with an EF <50%, 94.5% were improved or cured with cholecystectomy. In the group with an EF ≥50% and pain reproduction, the improved or cured rate was 83.4%. CCK-HIDA scans are useful for diagnosing biliary dyskinesia and predicting improvement after cholecystectomy. Patients presenting with biliary dyskinesia and an EF <50% on CCK-HIDA scan have 94% improvement or resolution of their symptoms after cholecystectomy. CCK-HIDA scans should be employed early in the evaluation of biliary colic with no evidence of cholelithiasis (i.e., with a normal ultrasound scan). When test results are abnormal, cholecystectomy should be performed, since the results in this setting approach those of cholecystectomy for stone disease (90% cured/improved). In the current climate of cost containment, these excellent results would obviate the need for extensive and expensive medical testing before surgical therapy is recommended.