Abnormal Gallbladder Ejection Fraction Research Articles

Sincalide-Stimulated Cholescintigraphy: A Retrospective Study and Proposal of a Modified Workflow.

Current guidelines for sincalide-stimulated cholescintigraphy (SSC) call for a 60-minute sincalide infusion, and a gallbladder ejection fraction (GBEF) ≥38% is considered normal. In this retrospective study, we hypothesize that most patients reach a normal GBEF by 30 minutes. Eligible patients had undergone a 60-minute SSC from January to December 2019. The clinical SSC data were previously processed on a Xeleris workstation (GE Healthcare). In subjects with GBEF ≥38% based on standard SSC, the GBEF at 20 minutes and 30 minutes were retrospectively calculated using manual pixel height measurements. Receiving operating characteristic was analyzed to determine the best GBEF cutoff at 30 minutes. Of 302 subjects, mean age of 46 ± 17 years, 33 (10.9%) showed an abnormal GBEF <38% suggestive of functional gallbladder disorder. In the remaining 269 patients (89.1%) with a normal GBEF, 60.6% and 86.6% reached a normal GBEF at 20 minutes and 30 minutes, respectively. Moreover, a GBEF threshold >29.1% at 30 minutes was associated with a negative predictive value of 99.6%, indicating that a 60-minute SSC was not necessary. The GBEF values were not associated with sex, age, patient symptoms, or type of referral. Manually calculated GBEFs on the time-activity curve showed excellent correlation with the primary values. We propose a modified workflow that splits the 60-minute SSC into two 30-minute image sets to allow for a screening GBEF at 30 minutes. If GBEF is >29.1% at 30 minutes, the second image set may be stopped, and the examination is complete. The majority of patients (77.2%) undergoing the standard 60-minute SSC reach a normal GBEF already by 30 minutes. The proposed workflow shortens the SCC procedure by 30 minutes, while maintaining high diagnostic accuracy and contributing to improved procedure efficiency and reduced patient discomfort as well as symptoms.

Clinical utility of stimulated cholescintigraphy using a standardized Ensure-Plus fatty meal protocol in patients with suspected functional gallbladder disorder: a retrospective study of seven-years clinical experience.

The clinical utility of fatty meal stimulated cholescintigraphy particularly using a standardized formulation in patients with suspected functional gallbladder disorder has not been extensively studied. We present our seven-year clinical experience using an Ensure plus protocol. A retrospective study was performed on patients undergoing stimulated cholescintigraphy using Ensure Plus for evaluation of suspected functional gallbladder disorder. A gallbladder ejection fraction (GBEF) of <33% was considered abnormal. Of the 173 patients evaluated, 57 (33%) had an abnormal GBEF, 112 (65%) had a normal GBEF and 4 (2%) had no gallbladder visualization. Of the 57 patients with an abnormal GBEF, symptom improvement occurred in 30/31 (97%) who underwent cholecystectomy and in 17/26 (65%) who were managed conservatively (p= 0.003). Of the 112 patients with a normal GBEF, symptom improvement occurred in 8/10 (80%) who underwent cholecystectomy and 74/102 (73%) who were managed conservatively (p= 1.000). In the subgroup of 102 patients with a normal GBEF managed conservatively, those without symptomatic improvement had lower GBEFs compared to those with symptomatic improvement (median GBEF 46% versus 57%, p= 0.019). Our retrospective results support a clinical role for stimulated cholescintigraphy using Ensure Plus in the evaluation of patients with suspected functional gallbladder disorder. While an abnormal GBEF predicts good surgical outcome, our results suggest that using an absolute GBEF cut off value of <33% may not apply to all patients and hence GBEF results should only be used as an adjunct in the surgical decision-making process.

Is abnormal gallbladder ejection fraction hokum? Retrospective chart review of gallbladder ejection fraction and subsequent postoperative symptom relief, surgical pathology, and current literature review.

The purpose of this report is to investigate the clinical importance of increased or decreased gallbladder ejection fraction (GBEF) and ultrasound findings for biliary dyskinesia by evaluating postsurgical symptom relief and surgical pathology. Single institution electronic medical record review was prepared for patients who underwent hepatobiliary iminodiacetic acid (HIDA) scan with GBEF and cholecystectomy between January 2013 and March 2020. Relevant data included patient demographics, ultrasound results, surgical pathology, HIDA with GBEF results, and postoperative symptom relief at the time of follow-up. Student's t-test was also utilized for additional statistical analysis. A total of 67 patients underwent cholecystectomy within a 1-month period of time after HIDA with GBEF. Of these patients, 97% had findings consistent with chronic cholecystitis and 3% of the patients demonstrated both acute and chronic cholecystitis surgical pathology. Fifty-seven percent of the patients demonstrated a GBEF <38%, 30% had a GBEF >80%, and 13% had a GBEF 38%–80% with a postoperative symptom resolution around 82%, 77%, and 100%, respectively. GBEF alone may not be determinative regarding gallbladder pathology or postoperative symptom relief in patients that present with typical symptoms. Regarding dyskinetic gallbladders, elevated and decreased GBEF groups were not significantly different in terms of surgical pathology or symptom relief. These patients may benefit from being treated as a single group rather than as separate entities. Elevated and decreased GBEF groups demonstrated mostly normal ultrasound results that raised concern for the utility of ultrasound as a rule out test for gallbladder inflammation.

Improving Hepatobiliary Imaging as a Physiologic Test with Superior Clinical Outcomes.

This study aims at prospectively evaluating the difference in the effect of cholecystokinin (CCK) and half-and-half milk (HHM) administered in the same patient on gallbladder contractility and correlation with clinical outcomes. Upon gallbladder visualization during standard hepatobiliary imaging, 0.02 μg/kg of CCK was injected over 3 min, and additional 30 min of dynamic imaging was obtained. Patients with gallbladder ejection fraction (GBEF) <35% after CCK were administered 8 oz of HHM followed by 30 min of imaging. The GBEF was recalculated. The number of patients whom GBEF changed from below 35% (abnormal) after CCK to above 35% (normal) after HHM was recorded. Follow-up of the clinical outcome at 6 months was performed. Fifty patients with abnormal GBEF were prospectively included. The average GBEF after CCK was 14.7% ± 8.5% and after HHM was 30.7% ± 20.8%. The average increase in GBEF with HHM was 16.0% ± 22.2%. The GBEF changed from abnormal to normal in 17 patients (34%). The remaining 33 patients remained abnormal. Clinical outcomes at 6 months were available in 47 patients. Cholecystectomy was performed in 60% of patients with abnormal GBEF with CCK and HHM with resolution or improvement of pain. Two of 16 patients (12%) with abnormal GBEF after CCK but normal after HHM had cholecystectomies with pain improvement, while 8 out of these patients (50%) were diagnosed and treated with other disorders and improved. Hepatobiliary imaging with HHM stimulation is a superior physiologic test which can lower the number of unnecessary cholecystectomies and misdiagnoses as functional cholecystitis.

Systematic review with meta-analysis: cholecystectomy for biliary dyskinesia-what can the gallbladder ejection fraction tell us?

Gallbladder dyskinesia (gallbladder spasm, biliary dyskinesia or chronic acalculous cholecystitis) is a poorly defined entity which presents as biliary-type pain without any identifiable organic pathology. Abnormal gallbladder ejection fraction (GBEF) is used by some to select those likely to benefit from cholecystectomy. The validity of this approach has been questioned. To systematically review the literature and summarise the evidence surrounding the practice of cholecystectomy based on GBEF for gallbladder dyskinesia. We conducted a systematic search of PubMed/MEDLINE and SCOPUS from 1980 to 2016 to identify the relevant literature. Twenty-nine studies including 2891 patients were included in the final analysis. In comparing cholecystectomy with medical management, patients with a normal GBEF did not benefit from cholecystectomy; whereas those with low GBEF had a higher chance (RR, relative risk=2.37) of symptomatic improvement following surgery. When those classified as "low" and "normal" GBEF were compared in terms of outcome following cholecystectomy, the rate of improvement following surgery was similar in the two groups (RR 1.09) which suggests a placebo effect of surgery. While a low GBEF may provide some guidance in identifying those with gallbladder dyskinesia who may benefit from cholecystectomy, the available data are inconsistent and based on studies of poor quality which are often subject to bias and the impact of confounding factors. For these reasons, we conclude that the role of scintigraphy and cholecystectomy in the definition and management of this disorder remain unclear pending definitive study.

Scintigraphic Findings Beyond Ejection Fraction on Hepatobiliary Scintigraphy: Are They Correlated With Chronic Gallbladder Disease?

To determine if classically reported findings associated with chronic cholecystitis on hepatobiliary scintigraphy (HBS), such as delayed small bowel (SB) transit, slow gallbladder (GB) filling, and reversal of the normal GB and SB transit, are associated with a depressed GB ejection fraction (GBEF). The secondary objectives were to determine whether GBEF is correlated with the time of GB filling, time of SB transit, or reversal of normal GB/SB filling sequence. We hypothesize that an association between a depressed GBEF and these classical HBS findings could validate them as surrogate markers for chronic GB disease. We reviewed all HBS exams over a retrospective 16-month period. Data from 221 patients (mean age, 45.3 ± 15.2 years; 152 female and 69 male subjects) who underwent HBS with GBEF determination for evaluation of chronic symptoms concerning for biliary etiology met inclusion criteria. Classically reported findings for cholecystitis were recorded for each patient. Comparisons were made using t test and Fisher test analysis. Comparing exams with normal and abnormal GBEF values, there were no significant differences based on age, sex, GB fill time, normal versus delayed SB transit, and reversal of normal GB/SB filling sequence. Additionally, we did not see a correlation between the measured GBEF and GB fill time, SB transit time, or reversal of normal GB/SB filling sequence. Delayed SB transit, slow GB filling time, and reversal of the normal GB and SB filling sequence on HBS imaging are not associated with the measured GBEF and not predictive of chronic GB disease.

Utility of HIDA Scan in Predicting Outcome of Cholecystectomy in Patients With Chronic Acalculous Gallbladder Disease? A Systematic Review

Introduction: HIDA scan with gallbladder ejection fraction (GBEF) is used to evaluate chronic acalculous gallbladder disease (CAGBD), in which abdominal pain is attributable to biliary dyskinesia or chronic acalculous cholecystitis. In current practice, cholecystectomy is recommended when the GBEF is abnormal. We conducted a systematic review to evaluate the value of HIDA to predict patient response after cholecystectomy. Methods: In consultation with librarian, a literature search was done in PubMed for studies from January 1st 1990 - October 31st, 2016 to identify manuscripts with patients with abdominal pain without gallstones who underwent HIDA followed by cholecystectomy, and where follow-up data on pain resolution following surgery was reported. After pooling data, summary statistics were calculated for positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity of HIDA with abnormal GBEF in detecting patients whose symptoms resolve after cholecystectomy. Results: Initial literature search identified 74 articles. 15 studies met the inclusion criteria. Only 1 randomized controlled trial was identified (Yap et al.), which was small and low quality. 722 patients underwent cholecystectomy in the abnormal GBEF group, out of which 658 reported improvement (PPV = 91.1%). In the normal GBEF group, 132 patients underwent cholecystectomy and 107 patients reported improvement (NPV = 18.9%). Overall the sensitivity of HIDA EF was fairly high at 86.0% but the specificity was low (28.1%), corresponding to a false positive rate of 71.9%. The overall positive likelihood ratio (LR) is 1.20 and negative LR is 0.50. Conclusion: While the sensitivity and PPV of HIDA for detecting patients who have cholecystectomy responsive CAGBD is fairly high, the specificity is alarmingly low. This means that the majority of patients who don't improve following cholecystectomy have abnormal HIDA scans preoperatively. Also, a relatively high proportion of patients with normal HIDA scans report improvement in symptoms following surgery, which undermines the value of test. These findings indicate that HIDA scans may be less valuable in selecting patients for cholecystectomy, as a test with a high specificity would be better for this purpose. We suggest that physicians perform comprehensive evaluations to rule out other causes of abdominal pain before proceeding to HIDA, and to interpret findings of HIDA with caution, as well as educate patients regarding the limitations.Figure: Test characteristics of HIDA scan.Table. 2x2: table with summary data for all patients with preoperative HIDA scans undergoing cholecystectomy.Table: Studies included in review.

Biliary Dyskinesia in Children: A Systematic Review.

Cholecystectomy rates for biliary dyskinesia in children are rising in the United States, but not in other countries. Biliary dyskinesia is a validated functional gallbladder disorder in adults, requiring biliary colic in the diagnosis. In contrast, most studies in children require upper abdominal pain, absent gallstones on ultrasound, and an abnormal gallbladder ejection fraction (GBEF) on cholecystokinin-stimulated cholescintigraphy for diagnosis. We aimed to systematically review existing literature in biliary dyskinesia in children, determine the validity and reliability of diagnostic criteria, GBEF, and to assess outcomes following cholecystectomy. We performed a systematic review following the PRISMA checklist and searched 7 databases including PubMed, Scopus, Embase, Ovid, MEDLINE, ProQuest, Web of Science, and the Cochrane library. Bibliographies of articles were screened for additional studies. Our search terms yielded 916 articles of which 28 were included. Three articles were manually added from searched references. We reviewed 31 peer-reviewed publications, all retrospective chart reviews. There was heterogeneity in diagnostic criteria and GBEF values. Outcomes after laparoscopic cholecystectomy varied from 34% to 100% success, and there was no consensus concerning factors influencing outcomes. The observational, retrospective study designs that comprised our review limited interpretation of safety and efficacy of the investigations and treatment in biliary dyskinesia in children. Symptoms of biliary dyskinesia overlapped with functional dyspepsia. There is a need for consensus on symptoms defining biliary dyskinesia, validation of testing required for diagnosis of biliary dyskinesia, and randomized controlled trials comparing medical versus surgical management in children with upper abdominal pain.

Liquid gastric emptying as an adjunct to hepatobiliary scintigraphy when oral corn oil is used as a cholecystagogue for determining gallbladder emptying.

During times of sincalide shortage, a fatty meal can be used to stimulate gallbladder contraction during hepatobiliary scintigraphy. However, if a patient has an abnormal gallbladder ejection fraction (GBEF), is the cause chronic cholecystitis or is it inadequate cholecystokinin stimulation due to poor gastric emptying? Hence, during the 2014 sincalide shortage, simultaneous liquid gastric emptying using (99m)Tc-sulfur colloid along with corn oil emulsion was initiated as routine practice in patients evaluated for GBEF. The objective of this study was to retrospectively assess the time course of gastric emptying in these patients, especially with regard to whether delayed gastric emptying may be a factor in some patients with a poor GBEF. My institution's clinical imaging procedure during the 2014 sincalide shortage consisted of routine (99m)Tc-mebrofenin hepatobiliary scintigraphy followed by corn oil emulsion and (99m)Tc-sulfur colloid orally. Dynamic imaging with regions of interest encompassing the gallbladder and the stomach allowed determination of GBEF and gastric emptying. For this study, the imaging records for 53 consecutive patients undergoing this clinical procedure were reviewed. The time for half gastric emptying, along with percentage gastric emptying at the end of imaging, was evaluated in relationship to GBEF. Seventeen patients had a normal GBEF (74% ± 14%) and satisfactory gastric emptying (31 ± 21 min for half emptying, 75% ± 14% emptying at end of imaging); 17 patients had a normal GBEF (77% ± 17%) despite unsatisfactory gastric emptying (only 30% ± 14% emptying at end of imaging); 5 patients had an abnormal GBEF (19% ± 9%) and satisfactory gastric emptying (26 ± 19 min for half emptying, 82% ± 14% emptying at end of imaging), supporting a diagnosis of chronic cholecystitis; 11 patients had an abnormal GBEF (26% ± 9%) but also unsatisfactory gastric emptying (only 26% ± 13% emptying at end of imaging), which did offer additional support for a diagnosis of chronic cholecystitis; and 3 patients had a borderline GBEF (40% ± 2%) with satisfactory gastric emptying (59% ± 6% emptying at end of imaging). Simultaneous liquid gastric emptying can provide additional information in the interpretation of GBEF when a fatty meal is used as an oral cholecystagogue, especially to help differentiate chronic cholecystitis from inadequate cholecystokinin stimulation due to poor gastric emptying.

Management of gallbladder dyskinesia: patient outcomes following positive 99mtechnetium (Tc)-labelled hepatic iminodiacetic acid (HIDA) scintigraphy with cholecystokinin (CCK) provocation and laparoscopic cholecystectomy

To evaluate clinical outcomes in patients with typical biliary pain, normal ultrasonic findings, and a positive (99m)technetium (Tc)-labelled hepatic iminodiacetic acid analogue (HIDA) scintigraphy with cholecystokinin (CCK) provocation indicating gallbladder dyskinesia, as per Rome III criteria, undergoing laparoscopic cholecystectomy (LC). Consecutive patients undergoing LC for gallbladder dyskinesia were identified retrospectively. They were followed up by telephone interview and review of the electronic case records to assess symptom resolution. One hundred consecutive patients (median age 44; 80% female) with abnormal gallbladder ejection fraction (GB-EF <35%) were followed up for a median of 12 months (range 2-80 months). Following LC, 84% reported symptomatic improvement and 52% had no residual pain. Twelve percent had persisting preoperative-type pain of either unchanged or worsening severity. Neither pathological features of chronic cholecystitis (87% of 92 incidences when histology available) nor reproduction of pain on CCK injection were significantly predictive of symptom outcome or pain relief post-LC. In one of the largest outcome series of gallbladder dyskinesia patients in the UK with a positive provocation HIDA scintigraphy examination and LC, the present study shows that the test is a useful functional diagnostic tool in the management of patients with typical biliary pain and normal ultrasound, with favourable outcomes following surgery.

Right upper quadrant pain with normal hepatobiliary ultrasound: Can hepatobiliary scintigraphy define the cause?

Background/Aim:The objective of this study was to assess the value of hepatobiliary scintigraphy (HS) for the diagnosis of right upper quadrant (RUQ) abdominal pain in patients with normal hepatobiliary ultrasound (HU). This is an observational study with a retrospective analysis of data from March 2008 to August 2010.Materials and Methods:We reviewed the HS results of 30 patients, aged 29–69 years (average 45.8 years); 12 male and 18 female patients. Patient selection to perform the HS was RUQ abdominal pain, suspected hepatobiliary disorder, and negative HU. All patients had gone through the standard procedure of HS.Results:Based on predefined interpretation criteria, HS results were divided into 2 patterns: Normal (n=8, 25.8%) and abnormal (n=22, 73%): 18 patients (81.8%) having early gallbladder (GB) and common bile duct visualization, and delayed transit to small bowel (SB), which can be seen only after a fatty meal with normal or abnormal GB ejection fraction (GBEF) pattern characteristic of Oddi's sphincter dyskinesia. The remaining 4 patients (8.18%) had acalculous cholycystitis pattern: Delayed GB visualization with activity appearing in SB before GB.Conclusion:HS with fatty meal stimulation and GBEF estimation seems to be a reliable test, which may reveal a biliary cause in more than 70% of patients with RUQ abdominal pain and normal HU. Normal results exclude functional biliary cause. The decision for invasive or noninvasive therapeutic approach may depend on the results of HS.

Lenalidomide-Induced Hepatotoxicity: A Case Report

Purpose: Lenalidomide is an immunomodulatory drug increasingly used for the treatment of patients with multiple myeloma and myelodysplastic syndromes. There is little data on hepatotoxicity related to this medication. We present a case of lenalidomide induced hepatotoxicity. Methods: A 67-year-old African-American male with known IgG lambda multiple myeloma was hospitalized with jaundice, fatigue, and vomiting. Patient was receiving second 3 week course of lenalidomide 25 mg orally daily, and dexamethasone 40 mg orally daily, when his symptoms appeared and progressively worsened during the 2nd week trial of therapy, resulting in hospitalization. When admitted, patient was found to be febrile (T-max 38.6 C) and have hyperbilirubinemia (peak value 4.4 g/dl) with direct biluribin predominance (peak value 3.3 g/dl). There was elevation of alkaline phosphatase (190 u/l), AST (145 u/l), and ALT (139 u/l). Concern for cholangitis was raised and antibiotic treatment initiated. Patient was also noted to have worsening of his chronically impaired kidney function (peak creatinine of 3.4 mg/dl). Imaging studies including abdominal ultrasound and subsequent MRCP revealed no cholelithiasis, normal caliber bile ducts without filling defects, and no other abnormalities. Hepatobiliary scan showed abnormal gallbladder ejection fraction and delayed biliary tract radio-isotope clearance. Patient was not receiving other hepatotoxic medications and serology was negative for viral hepatitis. Lenalidomide was considered to be potential cause of liver function tests abnormalities and this medication was discontinued. Consequently, hyperbilirubinemia normalized within the next 4 days. Other liver function tests also declined. Patient was found to have urinary tract infection thought to have caused the fever (resolved rapidly after initiating the antibiotic). Kidney impairment was established to be pre-renal, due to dehydration of nausea and vomiting. Renal function returned to baseline (creatinine of 1.7 mg/dl) with hydration. The patient improved clinically with described treatment allowing discharge 8 days after the initial presentation. Discussion: Coincidence of liver function impairment with lenalidomide treatment and discontinuation suggests possible hepatotoxic effect of this medication clinically presenting as cholestasis. Lenalidomide is mainly excreted by the kidneys and patients with reduced renal function may be at risk for related hepatotoxicity. Altered renal function and cholestatic presentation was also present in one of the other 2 published cases of lenalidomide related hepatotoxicity. Conclusion: Physicians should be aware of potential hepatotoxicity related to lenalidomide use, especially in patients with renal impairment.

Prevalence of Gall Bladder Dyskinesia in Gastroparesis

Purpose: The aim of this study is to assess the gall bladder ejection fraction (GBEF) by cholescintigraphy in a cohort of gastroparetic patients with prominent postprandial abdominal pain. Methods: 17 patients with gastroparesis (14 females) underwent the hydroxyl iminodiacetic acid (HIDA) scan to measure their GBEF over the last 2 years. A GBEF between 35%–50% on the HIDA scan was considered as a borderline positive test for gall bladder dysmotility and a GBEF < 35% was considered as definite evidence of gall bladder dyskinesia. Gastroparesis for this study was defined as retention of >10% of a standardized low fat isotope labeled egg beater meal at the end of 4 hours by scintigraphy. Demographic data, the etiology of gastroparesis, duration of gastroparetic symptoms, and bowel movement pattern were also recorded. Results: 11/17 (65%) of patients had a GBEF of < 50%, 8 of these patients had definite evidence of gall bladder dyskinesia, while the other 3 had a borderline positive test. 7/8 patients with a definitely positive test underwent cholecystectomy, of which 5 had chronic cholecystitis on pathology. 6/7 patients reported improvement in pain after the cholecystectomy. None of the patients with borderline evidence of gall bladder dysmotilily underwent cholecystectomy. Clinical characteristics of patients are summarized in table. There was no significant difference (p > 0.05) in age, or duration of gastroparetic symptoms in patients with normal and abnormal gall bladder ejection fraction. Gall bladder dysmotility was numerically more likely in females (OR 5; 95% CI: 0.35–72%), idiopathic gastroparesis (OR 5; 95% CI: 0.6–46), and in patients with constipation (OR 2; 95% CI: 0.2–13) Conclusion: 1) This pilot study shows that gall bladder dysmotility is present in a majority of patients with gastroparesis; particularly of idiopathic etiology 2) Underlying neuromuscular dysfunction in gastroparesis may also extend to the gall bladder, consistent with a neuropathic etiology to explain the gall bladder dyskinesia. 3) Appreciating the need to diagnose and treat biliary dyskinesia in gastroparesis could be an important strategy to address the pain component in this challenging clinical setting.Table: Clinical Characteristics of gastroparetic patients who underwent HIDA scan

CAN GALLBLADDER EJECTION FRACTION ON HIDA SCANS PREDICT ABNORMAL GALLBLADDER PATHOLOGY UPON CHOLECYSTECTOMY?

Background: Cholecystokinin-Hepatobiliary Scan (HIDA) is often obtained to assess gallbladder function in patients with chronic abdominal pain. There are contradictory findings in the literature regarding the relationship between a diminished gallbladder ejection fraction (GBEF) and pathological abnormality of the gallbladder (GB). Dumont RC et al. found that 20 of 42 (48%) children who had a cholecystectomy for biliary dyskinesia had pathologic findings of chronic inflammation. However, Goncalves et al. showed 42 of 44 (95%) children showed chronic cholecystitis. Our aim was to evaluate the relationship of a diminished Gallbladder Ejection Fraction (GBEF) on HIDA with gallbladder pathology in a large population of pediatric patients. Methods: The medical records of 289 children who underwent cholecystectomy from 1998 - 2005 at Kosair Children's Hospital were reviewed. 104 of these children also underwent HIDA Scan. An abnormal value for the HIDA Scan was defined as <35% ejection fraction. Chi-square analysis, Positive Predictive Value, and Negative Predictive Value were calculated to determine whether diminished GBEF predicted GB pathology. Results: Patient ages ranged between 6 and 18 years. Of those with abnormal HIDA (96 patients), 55 (57%) had abnormal GB pathology. Of those with normal HIDA (8 patients), 5 (63%) had abnormal GB pathology. Abnormal GBEF Positive Predictive Value was 57%; Negative Predictive Value was 38%. Chi-square analysis revealed a p-value of 0.082 for abnormal HIDA scan inability to predict abnormal GB pathology. Conclusions: GBEF remains a controversial predictor in the determination of GB pathology. Although this study shows that abnormal HIDA scan statiscally predicts abnormal GB pathology, our findings suggest that an abnormal GBEF does not reliably indicate GB disease and delineates the limitations of the HIDA Scan. This further emphasizes the importance of the history and physical examination with regard to need for cholecystectomy.

Long-Term Evaluation of Biliary Dyskinesia in Pediatrics

Purpose: Biliary dyskinesia, a motility disorder of the gallbladder, causes poor emptying and pain. Quantitative cholecystokinin cholescintigraphy (QCC) identifies patients with abnormal gallbladder emptying. Ten patients (8 female, 2 male, mean age 13.8 y) with chronic right upper quadrant pain were evaluated for biliary dyskinesia using QCC. Abdominal complaints were present for a mean of 13.6 months. Epigastric pain, nausea and vomiting, food intolerance and diarrhea and/or constipation were also reported. Methods: Abdominal ultrasound, upper GI series and abdominal CT scan were done. Abnormal gallbladder ejection fractions after cholecystokinin were defined as less than 35% excretion. Results: Nine patients had normal endoscopies with one showing histological evidence of esophagitis. All patients had normal liver function. None of the patients had Helicobacter pylori. The average gallbladder ejection fraction in this group of patients was 16.97%. All 10 patients had a laparoscopic cholecystectomy and histology showed mild chronic cholycystitis in 8 of 10 patients; two had normal gallbladders. Gallstones were found surgically in 2 patients that had normal imaging studies. The mean follow up period following surgery was 23.8 months. The four patients with significant right upper quadrant pain before surgery had complete resolution of their abdominal symptoms following cholecystectomy with no other significant gastrointestinal complaints. The six patients who had continuing abdominal complaints following surgery reported right upper quadrant pain in addition to a combination of epigastric pain, vomiting and or constipation/diarrhea before surgery. Conclusions: (1) Cholecystectomy may not relieve all abdominal complaints in documented cases of biliary dyskinesia. (2) Cases of biliary dyskinesia with abdominal complaints confined to the right upper quadrant are more likely to respond to cholecystectomy. (3) Cases of biliary dyskinesia with multifocal abdominal complaints are less likely to respond completely to cholecystectomy. (4) Biliary dyskinesia may be part of a more global motility disturbance.

Ultrasonographic evaluation of fatty meal stimulated gallbladder contraction in the diagnosis of biliary dyskinesia in children

Abstract Aim: Biliary dyskinesia (BD) is characterized by symptoms of biliary disease, no evidence of gallstones on ultrasonography (USG), and diminished gallbladder ejection fraction. The diagnosis is based on findings of abnormal gallbladder ejection fraction diagnosed by hepatobiliary scintigraphy before and after stimulation of gallbladder contraction with cholecystokinin (CCK). We used an easier diagnostic technique defined as ultrasonographic evaluation of fatty meal stimulated gallbladder contraction, employing USG with the diagnosis of biliary dyskinesia in children. The study was conducted by USG to investigate the volume and contractility of the gallbladder (GB) in fasting conditions and 45 min after a standardized fatty meal (SFM) in normal children and in a group of BD patients, and to compare the diagnostic value of this test with scintigraphy and to evaluate its use as a new method in the diagnostic algorithm of BD. Methods: We assessed the volume changes and contractility of the GB in response to SFM by USG in 14 patients with BD diagnosed by cholecystokinin stimulated hepatobiliary scintigraphy (CCKs‐HBS); and compared them with 14 control patients matched for age and gender before cholecystectomy. After an overnight fasting, GB volume was measured by USG then the GB volume was again measured after the SFM ingestion. Using USG, length, width and height of GB were measured, and volume of the GB was calculated using the ‘Dodds’ formula. These volume measurements were used to calculate the percentage of gallbladder emptying (ejection fraction). Fasting, after SFM and EF values comparisons between groups were done with student's t‐test. Results: No statistically significant difference of fasting GB volumes were demonstrated between BD and control groups (14.1±6.7 cm3 and 13.4±4.0 cm3 respectively). GB volumes of the BD group after SFM were significantly greater than in healthy controls (13.1±1.8 cm3 and 3.4±0.9 cm3 respectively, P&lt;0.0005). The calculated percentage of gallbladder contraction (ejection fraction) was found to be lower in BD patients than in healthy controls (7.1%±1.8% and 73.8%±6.4%, respectively, P&lt;0.0005). Conclusion: Ultrasonographic evaluation of fatty meal stimulated gallbladder contraction provides relatively reliable and reproducible results. Thus it can be used for scanning in patients with biliary symptoms as a prior modality to CCK‐HBS since it is a relatively easier, safer and available method with which to make a definitive diagnosis of BD. The patients with symptoms of biliary disease and no evidence of gallstones on USG should be evaluated by the method proposed in this study before the routine laboratory and radiologic tests.

Ultrasonographic evaluation of fatty meal stimulated gallbladder contraction in the diagnosis of biliary dyskinesia in children

Biliary dyskinesia (BD) is characterized by symptoms of biliary disease, no evidence of gallstones on ultrasonography (USG), and diminished gallbladder ejection fraction. The diagnosis is based on findings of abnormal gallbladder ejection fraction diagnosed by hepatobiliary scintigraphy before and after stimulation of gallbladder contraction with cholecystokinin (CCK). We used an easier diagnostic technique defined as ultrasonographic evaluation of fatty meal stimulated gallbladder contraction, employing USG with the diagnosis of biliary dyskinesia in children. The study was conducted by USG to investigate the volume and contractility of the gallbladder (GB) in fasting conditions and 45 min after a standardized fatty meal (SFM) in normal children and in a group of BD patients, and to compare the diagnostic value of this test with scintigraphy and to evaluate its use as a new method in the diagnostic algorithm of BD. We assessed the volume changes and contractility of the GB in response to SFM by USG in 14 patients with BD diagnosed by cholecystokinin stimulated hepatobiliary scintigraphy (CCKs-HBS); and compared them with 14 control patients matched for age and gender before cholecystectomy. After an overnight fasting, GB volume was measured by USG then the GB volume was again measured after the SFM ingestion. Using USG, length, width and height of GB were measured, and volume of the GB was calculated using the 'Dodds' formula. These volume measurements were used to calculate the percentage of gallbladder emptying (ejection fraction). Fasting, after SFM and EF values comparisons between groups were done with student's t-test. No statistically significant difference of fasting GB volumes were demonstrated between BD and control groups (14.1+/-6.7 cm3 and 13.4+/-4.0 cm3 respectively). GB volumes of the BD group after SFM were significantly greater than in healthy controls (13.1+/-1.8 cm3 and 3.4+/-0.9 cm3 respectively, P<0.0005). The calculated percentage of gallbladder contraction (ejection fraction) was found to be lower in BD patients than in healthy controls (7.1%+/-1.8% and 73.8%+/-6.4%, respectively, P<0.0005). Ultrasonographic evaluation of fatty meal stimulated gallbladder contraction provides relatively reliable and reproducible results. Thus it can be used for scanning in patients with biliary symptoms as a prior modality to CCK-HBS since it is a relatively easier, safer and available method with which to make a definitive diagnosis of BD. The patients with symptoms of biliary disease and no evidence of gallstones on USG should be evaluated by the method proposed in this study before the routine laboratory and radiologic tests.

Functional Gallbladder and Sphincter of Oddi Disorders

The functional disorder of the gallbladder (GB) is a motility disorder caused initially either by metabolic abnormalities or by a primary motility alteration. The functional disorders of the sphincter of Oddi (SO) encompass motor abnormalities of either the biliary or the pancreatic SO. Dysfunction of the GB and/or biliary SO produce similar patterns of pain. The pain caused by a dysfunction of the pancreatic SO can be similar to that of acute pancreatitis. The symptom-based diagnostic criteria of motility dysfunction of the GB and biliary SO are episodes of moderate to severe steady pain located in the epigastrium and right upper abdominal quadrant that last at least 30 minutes. GB motility disorder is suspected after gallstones and other structural abnormalities have been excluded. This diagnosis should then be confirmed by a decreased GB ejection fraction induced by cholecystokinin at cholescintigraphy and after disappearance of the recurrent biliary pain after cholecystectomy. Symptoms of biliary SO dysfunction may be accompanied by features of transient biliary obstruction, and those of pancreatic SO dysfunction are associated with elevation of pancreatic enzymes and even pancreatitis. Biliary-type SO dysfunction is more frequently recognized in postcholecystectomy patients. SO manometry is valuable to select patients with sphincter dysfunction; however, because of the high incidence of complications, these patients should be referred to an expert unit for such assessment. Thus invasive tests should be performed only in the presence of compelling clinical evidence and after noninvasive testing has yielded negative findings. The committee recommends that division of the biliary or pancreatic sphincters only be considered when the patient has severe symptoms, meets the required criteria, and other diagnoses are excluded.

Usefulness of gallbladder ejection fraction estimation to predict the recurrence of biliary pain in patients with symptomatic gallstones who did not undergo cholecystectomy.

This study was performed to evaluate any predictable factors associated with recurrence of biliary pain in symptomatic gallstone patients who did not undergo cholecystectomy because of operative risk, advanced age, and/or their refusal. The relationships among age, gender, body mass index, frequency of biliary pain before diagnosis, period between the last symptom attack and the hospital visit, size and number of gallstones, gallbladder ejection fraction (GBEF), compliance of ursodeoxycholic acid therapy, and recurrence of biliary pain were examined. The recurrence of biliary pain developed in 15 of 31 patients during the median 29-month follow-up. The cumulative 1-, 2-, and 3-year recurrence rates of biliary pain were 22.8, 40.9, and 53.0% and significantly associated with abnormal GBEF (hazard ratio, 3.12; 95% CI, 1.10-8.87; P = 0.032). In symptomatic gallstone patients with abnormal GBEF, cholecystectomy is strongly advisable because of the high risk of repeated pain attacks.

Does gallbladder ejection fraction predict outcome after cholecystectomy for suspected chronic acalculous gallbladder dysfunction? A systematic review.

The clinical utility of cholecystokinin-cholescintigraphy with calculation of a gallbladder ejection fraction (GBEF) in patients with suspected chronic acalculous gallbladder dysfunction (CAGD) remains controversial. It was our aim to critically evaluate the literature on the utility of the GBEF to predict outcome of patients with suspected CAGD. We performed an electronic search of the MEDLINE database for articles published between 1980 and 2002 and a manual search of references from bibliographies of identified articles. Only articles in English that concerned adults were screened. Data extracted included both qualitative and quantitative data reported on the study groups, cholescintigraphic technique, interventions, treatment outcomes, and trial methodologic characteristics. Twenty-three publications met the inclusion criteria. All were considered of poor methodologic quality. All but three studies were retrospective case series, only one was randomized, and none were adequately blinded, used adequate controls, or enrolled a sufficient number of patients. Five studies used a cut-off value for an abnormal GBEF that was different than the value used by the others, one study did not provide a cut-off value, and several did not report details of the cholescintigraphic technique (namely, the rate of cholecystokinin infusion). Studies varied in their outcome measures and the criteria for success. The overall assessment of outcome in 19 studies concluded that calculation of a GBEF was useful in patients with suspected CAGD. The low methodologic quality of the studies precluded a meta-analysis approach to the data. Use of a calculated GBEF to diagnose and predict treatment outcome in suspected CAGD has not been adequately studied. Although most studies report utility of GBEF in predicting symptom outcome after cholecystectomy in patients with suspected CAGD, quality evidence is lacking, thereby precluding a definitive recommendation regarding its use. More high quality trials are needed.