Chronic Acalculous Gallbladder Disease Research Articles

Sincalide: A Review of Clinical Utility, Proper Infusion Methodology, and Alternative Cholecystogogues.

Sincalide (Kinevac) is widely used in conjunction with cholescintigraphy for a variety of clinical indications. Over the years, numerous publications have verified the optimal infusion methodology. Published data and consensus recommendations emphasize that sincalide, 0.02 μg/kg, should be infused over 60 min. Production problems sometimes limit the availability of sincalide. In that case, non-Food and Drug Administration pharmacy-compounded sincalide may serve as an alternative. Fatty meals have also been used. Various illnesses and drugs may inhibit gallbladder contraction. Thus, these drugs should be withheld for 48 h before the study. Sincalide cholescintigraphy is most commonly used to diagnose or exclude chronic acalculous gallbladder disease. The study should preferably be performed as an outpatient procedure.

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.

Pain provocation and low gallbladder ejection fraction with CCK cholescintigraphy are not predictive of chronic acalculous gallbladder disease symptom relief after cholecystectomy.

Chronic acalculous gallbladder disease (CAGD) falls within the spectrum of diseases associated with gallbladder dysmotility. Cholecystokinin-cholescintigraphy (CCK-CS) has been used to evaluate for CAGD, with a gallbladder ejection fraction (GBEF) of <35% being indicative of gallbladder dysfunction. The reproduction of biliary colic upon administration of CCK has been cited as indicative of CAGD. Our purpose was to determine whether low GBEF or reproduction of pain during CCK-CS was predictor of surgical outcomes related to resolution of symptoms or as a correlate to gallbladder pathology. A retrospective review of patients was performed to evaluate adults with a diagnosis of CAGD who underwent CCK-CS prior to surgical intervention. CPT and ICD-9 coding queries were used to identify the patient population. Patients with cholelithiasis were excluded. Sixty-four patients met inclusion criteria. Two patients were lost to follow-up and were excluded. During CCK-CS, 41 patients (66%) reported symptoms similar to their presenting complaint. Twenty-one patients reported no symptoms with CCK-CS. There was no significant relationship between gallbladder pathology and either GBEF or reproduction of symptoms with CCK-CS (p=0.14). About 81% of patients (n=50) had relief of symptoms following cholecystectomy. Sixty-six percentage of patients (n=33) with long-term symptom relief after cholecystectomy had reproduction of symptoms with CCK-CS. Nineteen percentage of all patients (n=12) had long-term symptom recurrence despite surgery. Eight of these patients (66%) had symptom reproduction with CCK-CS. There was no significant correlation with either the GBEF or symptoms reproduction with CCK-CS as a predictor of postoperative outcome (p=0.12). Provocation of pain by CCK-CS and low GBEF are unreliable predictors of postoperative relief of symptoms following cholecystectomy for biliary dyskinesia or chronic acalculous gallbladder disease.

Hepatobiliary scintigraphy in 2014.

Cholescintigraphy with (99m)Tc-hepatobiliary radiopharmaceuticals has been an important, clinically useful diagnostic imaging study for almost 4 decades. It continues to be in much clinical demand; however, the indications, methodology, and interpretative criteria have evolved over the years. This review will emphasize state-of-the-art methodology and diagnostic criteria for various clinical indications, including acute cholecystitis, chronic acalculous gallbladder disease, high-grade and partial biliary obstruction, and the postcholecystectomy pain syndrome, including sphincter-of-Oddi dysfunction and biliary atresia. The review will also emphasize the use of diagnostic pharmacologic interventions, particularly sincalide.

Nuclear medicine hepatobiliary imaging (cholescintigraphy)

Nuclear medicine hepatobiliary imaging (cholescintigraphy)

T1625 Is Pain Provocation With Cholecystokinin Administration on Cholescintigraphy Predictive of Relief of Symptoms for Biliary Dyskinesia Following Cholecystectomy?

Introduction Biliary dyskinesia, also referred to as chronic acalculous gallbladder disease (CAGD), falls within the spectrum of diseases associated with gallbladder dysmotility. Cholecystokinin cholescintigraphy (CCK-CS) has been used to evaluate for CAGD, with a gallbladder ejection fraction (GBEF) of <35% being indicative of gallbladder dysfunction. The reproduction of biliary colic upon administration of CCK has been cited as indicative of CAGD. Our purpose was to determine if reproduction of pain during CCK-CS is a predictor of surgical outcomes or as a correlate to pathology. Methods A retrospective review of patients was performed to evaluate adults with a diagnosis of CAGD who underwent CCK-CS prior to surgical intervention. CPT and ICD-9 coding queries were used to identify the patient population. Patients with cholelithiasis were excluded. This study was approved by the institutional Human Assurances Committee. Results 64 patients met inclusion criteria. Two patients were lost to follow up and were excluded. During CCK administration, 41 patients (66.13%) reported symptoms similar to their presenting complaint. 21 patients reported no symptoms with CCK administration. Pathology review demonstrated either normal histology (n=4), cholesterolosis (n=4), chronic cholecystitis (n=47), both cholesterolosis and chronic cholecystitis (n=6), or autolysis (n=1). There was no significant relationship between pathology and either GBEF or reproduction of symptoms with CCK administration. 81% of patients (n=50) had relief of symptoms following cholecystectomy (mean EF of 19.55% ± 12.16%). 33 of these patients (66.00%) had reproduction of symptoms with CCK-CS. Twelve patients had recurrence of symptoms (mean EF of 17.18% ± 7.59%) despite surgery. Eight of these patients (66.67%) had symptom reproduction with CCK administration. There was no significant correlation with either the EF or reproduction of symptoms following CCK administration as a predictor of postoperative outcome on assessment by unpaired Student's t-test. Conclusion Provocation of pain CCK-CS is an unreliable indicator of postoperative relief of symptoms than GBEF.

Nuclear Medicine Hepatobiliary Imaging

Nuclear medicine hepatobilary imaging (HIDA) is a time proven imaging methodology that uses radioactive drugs and specialized cameras to make imaging diagnoses based on physiology. HIDA radiopharmaceuticals are extracted by hepatocytes in the liver and cleared through the biliary system similar to bilirubin. The most common indication for HIDA imaging is acute cholecystitis, diagnosed by nonfilling of the gallbladder due to cystic duct obstruction. HIDA can detect high grade biliary obstruction prior to ductal dilatation; images reveal a persistent hepatogram without biliary clearance due to the high backpressure. HIDA also aids in the diagnosis of partial biliary obstruction due to stones, biliary stricture, and sphincter of Oddi obstruction. It can confirm biliary leakage postcholecystectomy and hepatic transplantation. Calculation of a gallbladder ejection fraction after cholecystokinin infusion is commonly used to diagnose chronic acalculous gallbladder disease. Diseased gallbladders do not contract. There are many other less common but valuable diagnostic indications for HIDA imaging.

Gallbladder muscle dysfunction in patients with chronic acalculous disease

Background & Aims: The mechanisms responsible for the abnormalities of gallbladder emptying in patients with chronic acalculous gallbladder disease (AGD) have not been elucidated. This study was designed to determine whether a muscle defect could explain this gallbladder dysfunction. Methods: Gallbladder contraction induced by a continuous intravenous cholecystokinin octapeptide (CCK-8) infusion was determined by ultrasonography in control subjects, patients with AGD, pigment stones, and cholesterol stones. Muscle cells were obtained by enzymatic digestion. 125I–CCK-8 binding and [35S]guanosine triphosphate γS (GTPγS) binding studies were performed. Results: In vivo gallbladder contraction induced by CCK-8 was significantly lower in AGD (29.4%) and cholesterol stones (28.8%) than in pigment stones (59.8%) and normal controls (57.8%; P < 0.01). In vitro muscle cell contraction induced by CCK-8 was also lower in AGD than in pigment stones. It remained impaired in AGD after stimulation with the G-protein activators GTPγS and AlF4 and with the second messenger 1,2-dioctanoyl-sn-glycerol. However, GTPγS binding induced by CCK-8 and vasoactive intestinal polypeptide and the binding capacity of CCK receptors were not different between AGD and pigment stones. Conclusions: These findings suggest that there is a good correlation between in vivo and in vitro gallbladder response to CCK-8 in patients with AGD. Unlike those found in cholesterol stones, the muscle defects in AGD appear to reside in the contractile apparatus.GASTROENTEROLOGY 2001;120:506-511

Chronic Acalculous Gallbladder Disease

A review of 228 cholecystectomies done over a two-year period revealed 15 cases (6.6%) in which gallstones were absent. These 15 patients were all characterized by colicky abdominal pain in the right upper quadrant, with a mean duration of eight months. Ultrasonographic examination was falsely positive for gallstones in one third (5/15) of the patients, and further diagnostic evaluation in the remaining two thirds (10/15) failed to define a clear-cut surgical problem. All 15 patients ultimately had operation on the basis of symptoms. Every patient reported resolution of preoperative symptoms at short-term follow-up (four to eight weeks). Seven patients available for long-term follow-up (ten to 27 months) reported complete symptomatic resolution. The postoperative outcome failed to correlate reliably with gallbladder histology, bile cultures, and results of diagnostic testing. There was no mortality, and morbidity was limited to three patients. This series confirms previous reports of a small set of relatively young, healthy patients having chronic disabling symptoms of gallbladder disease in the absence of gallstones. Our results suggest that the most reliable factor predicting a successful outcome of cholecystectomy in these patients was the presence of severe biliary colic.

Chronic acalculous gallbladder disease: multiimaging evaluation with clinical-pathologic correlation.

Despite the recent advances in hepatobiliary imaging, the diagnosis of chronic acalculous gallbladder disease remains difficult. A retrospective study was undertaken to assess the value of a multiimaging approach in detecting chronic acalculous gallbladder disease and in predicting which patients would obtain symptomatic relief after cholecystectomy. Of 199 patients with chronic cholecystitis, 26 (13%) had no gallstones. Of these 26, only 17 (65%) had symptoms related to chronic cholecystitis; in the remainder, the histologic diagnosis was made incidentally. After cholecystectomy, 13 (76%) of the 17 symptomatic patients obtained long-term symptomatic relief, while in four, the symptoms recurred. Among patients with histologic changes of chronic cholecystitis, biliary scintigraphy was the most sensitive technique (sensitivity, 89%). The sensitivity of sonography and oral cholecystography was 61.5% and 66%, respectively. However, for identifying symptomatic patients who may obtain long-term symptomatic relief after cholecystectomy, the accuracy of sonography, oral cholecystography, and biliary scintigraphy was 82%, 86%, and 38%, respectively. When two tests were in agreement the accuracy was 88%. For chronic acalculous cholecystitis, more than one study must be performed in order to make the correct diagnosis and to predict good results from cholecystectomy.

Chronic acalculous gallbladder disease

Chronic acalculous gallbladder disease

Chronic acalculous gallbladder disease: a clinical enigma.

AbstractPatients with classic symptoms of gallbladder disease who have negative oral cholecystograms (OCG) or ultrasonography present perplexing management problems. The surgical literature attests to the fact that there is a marked difference of opinion as to the role of surgery in these patients. The high recurrence rate of symptoms in patients following surgery reported in some series has been a source of major concern.We have attempted to define the appropriate approach to this problem for the past decade. Initially, the findings of prolonged visualization of the gallbladder on OCG in association with a fatty meal was considered an indication for surgery. This initial group of patients followed over a decade showed about 75% to be symptom free. Subsequently, additional patients were subjected to cholecystokinin oral cholecystography (CCK‐OCG). With follow‐up for over 6 years, the results have shown about 80% relief of biliary tract symptoms in these patients (CCK‐OCG category) following surgery.Continued attempts to further define those patients who will benefit from surgery has resulted in the utilization of radionuclide imaging in association with cholecystokinin injection (CCK‐RNI). One hundred patients were subjected to CCK quantitative biliary imaging. Seventy‐six patients were considered to have inadequate gallbladder emptying; 30 patients with no gallbladder emptying on CCK‐RNI were subjected to cholecystectomy. All patients subjected to cholecystectomy showed abnormal histological findings in the gallbladder. These 30 patients have been followed from 1 to 3 1/2 years and there has been no recurrence of symptoms in any following surgery.