Functional Gallbladder Disorder Research Articles

Функциональные расстройства желудочно- кишечного тракта у детей дошкольного возраста: современные подходы к терапии

Recurrent abdominal pain (RAP) syndrome is a common pathology of childhood, which is often encountered in pediatric outpatient practice. Currently, pharmacological options are insufficiently developed, in this regard, we decided to use the drug trimebutin in the form of powder for preparation of suspension for oral administration for the treatment of this group of patients. Objective. To evaluate the effect of trimebutine therapy in the form of powder for preparation of oral suspension on the course of pain syndrome and a number of associated symptoms in preschool patients with functional RAP syndrome. Patients and methods. The study included 84 children aged 3 to 5 years who applied to the consultative and diagnostic clinic "Gastroenterological Center" (Ufa, Republic of Bashkortostan). The diagnosis of functional gastrointestinal disorders (FGD) was established in 53 patients (63.1%) of the total number of patients aged 3 to 5 years with RAP. Results. Complete disappearance of symptoms occurred in 48 (90.5%) outpatients. Commitment to treatment was high in the majority of patients (73.6%, 39 children), which, among other things, ensured high efficacy of the therapy. Conclusion. Trimebutin in the form of powder for suspension preparation in our study showed excellent efficacy in the management of RAP syndrome and associated symptoms, which is extremely valuable for determining the tactics of therapy of this pathology in preschool children in pediatric practice. The drug was well tolerated by patients, which ensured high adherence to treatment. Key words: recurrent abdominal pain, functional gastrointestinal disorders, functional dyspepsia, irritable bowel syndrome, functional gallbladder disorder, sphincter of Oddi dysfunction, functional abdominal pain, trimebutin, Trimedate

The value of HIDA scan for functional gallbladder disorder: a clinical pathoradiological correlation and outcome study

The value of HIDA scan for functional gallbladder disorder: a clinical pathoradiological correlation and outcome study

Cholescintigraphic evaluation of gallbladder contraction in correlation with serum thyrotropin and serum cholesterol

Background and aims: To study the effect of serum thyrotropin (Sr.TSH) and serum cholesterol on gallbladder contraction by cholescintigraphy. Methods: This is a prospective cross-sectional study comprising 77 patients for evaluation of gallbladder function in patients with biliary pain. All of them underwent 99mTc- Mebrofenin fatty meal cholescintigraphy following a standard institutional protocol apart from regular investigations. Dynamic images were acquired for 90 minutes with a standardised fatty meal given at the 60th minute. Gallbladder emptying kinetics was determined with Gallbladder Ejection Fraction (GBEF) calculated at 30 minutes post-meal. Relevant statistical methods were applied for interpretation. Results: The mean of GBEF was 60.82% ± 16.65% and the mean of Sr.TSH was 3.72 ± 3.88 mIU/ml, there was a negative correlation between GBEF and Sr.TSH (Pearson correlation coefficient r = -0.535, p < 0.05). The mean serum cholesterol was 180.61 ± 46.34 mg/dl, there was a negative correlation between GBEF and serum cholesterol (Pearson’s correlation coefficient r = -0.685, p < 0.05). The mean GBEF in euthyroid and hypothyroid patients were 65.04% ± 15.04% and 47.27% ± 15.93% respectively (P < 0.05). Conclusion: Hypothyroidism is one of the key factors affecting gallbladder contractility and should not be overlooked in the management of functional gallbladder disorders. Cholescintigraphy can accurately assess gallbladder function qualitatively and quantitatively, and it can help (aid) physicians in diagnosing and decision-making on the management of biliary pain in hypothyroidism.

Functional gallbladder disorder: Interim analysis of a prospective cohort study

BackgroundFunctional gallbladder disorder (FGBD) remains a controversial indication for cholecystectomy. MethodsA prospective cohort study enrolled patients strictly meeting Rome criteria for FGBD, and cholecystectomy was performed. They were assessed pre- and 3 and 6 months postoperatively with surveys of abdominal pain and quality of life (RAPID and SF-12 surveys, respectively). Interim analysis was performed. ResultsAlthough neither ejection fraction nor pain reproduction predicted success after cholecystectomy, the vast majority of enrolled patients had a successful outcome after undergoing cholecystectomy for FGBD: of a planned 100 patients, 46 were enrolled. Of 31 evaluable patients, 26 (83.9 ​%) reported RAPID improvement and 28 (93.3 ​%) SF12 improvement at 3- or 6-month follow-up. ConclusionFGBD, strictly diagnosed, should perhaps no longer be a controversial indication for cholecystectomy, since its success rate for biliary pain in this study was similar to that for symptomatic cholelithiasis. Larger-scale studies or randomized trials may confirm these findings.

Use of a Fatty Meal Cholecystagogue Protocol in Hepatobiliary Scintigraphy for Chronic Functional Gallbladder Disease.

Chronic functional gallbladder disorder, characterized by biliary pain in the absence of structural pathology, poses a diagnostic challenge necessitating reliable cholecystagogues for accurate evaluation. However, recurrent shortages of synthetic cholecystokinin analogs have prompted the exploration of alternative agents. This paper describes the efficacy of Ensure Plus as a viable fatty meal substitute for hepatobiliary scintigraphy in assessing chronic functional gallbladder disorder. Through comparative studies, Ensure Plus demonstrates comparable diagnostic accuracy to cholecystokinin in similar patient populations. Furthermore, Ensure Plus demonstrates significant symptom improvement after cholecystectomy in patients with anomalous gallbladder ejection fractions. This paper offers a detailed protocol for the seamless integration of Ensure Plus into hepatobiliary scintigraphy, providing clinicians with a valuable tool to navigate cholecystokinin shortages while maintaining diagnostic precision in cases of chronic functional gallbladder disorder. The use of Ensure Plus not only addresses practical supply challenges but also underscores its potential as a cost-effective and clinically sound alternative in biliary diagnostics.

A Biophysical Approach to Functional Gallbladder Disorder Leads to the Hypothesis That Salmonella Plays a Relevant Role in the Etiology of This Disease: A Retrospective Observational Pilot Study

A Biophysical Approach to Functional Gallbladder Disorder Leads to the Hypothesis That Salmonella Plays a Relevant Role in the Etiology of This Disease: A Retrospective Observational Pilot Study

Defining Biliary Hyperkinesia and the Role of Cholecystectomy.

Functional gallbladder disorder is most commonly defined by biliary colic and low ejection fraction (EF) on cholescintigraphy. Biliary hyperkinesia is a controversial type of functional gallbladder disorder, and its definition and the role of cholecystectomy in treating functional gallbladder disorder remains unclear. We conducted a retrospective review of patients who underwent cholecystokinin-stimulated cholescintigraphy and cholecystectomy at 3 Mayo Clinic sites between 2007 and 2020. Eligible patients were 18 years or older, presented with symptoms of biliary disease, had an EF greater than 50%, underwent cholecystectomy, and had no evidence of acute cholecystitis or cholelithiasis on imaging. We used receiver operating characteristics curve analysis to identify the optimal cutoff value that predicted symptom resolution within 30 days of cholecystectomy. A total of 2,929 cholecystokinin-stimulated cholescintigraphy scans were performed during the study period; the average EF was 67.5% and the median EF was 77%. Analyzing those with EFs greater than or equal to 50% yielded 1,596 patients with 141 (8.8%) going on to have cholecystectomy. No significant differences were found in age, sex, BMI, final pathology between patients with and without pain resolution. Using a cutoff EF of 81% was significantly associated with pain resolution after cholecystectomy (78.2% for EF greater than or equal to 81% vs 60.0% for EF less than 81%, p = 0.03). Chronic cholecystitis was found in 61.7% of the patients on final pathology. We determined that an EF cutoff of 81% is a reasonable upper limit of normal gallbladder EF. Patients with biliary symptoms and an EF greater than 81% but no evidence of biliary disease on ultrasound or scintigraphy can be classified as having biliary hyperkinesia. Based on our findings, we recommend cholecystectomy for this patient population.

Functional gallbladder disorder: Interim analysis of a prospective cohort study

Background: Functional gallbladder disorder (FGBD) is a controversial indication for cholecystectomy (CCY) in the United States, and is rarely done at all in Europe. The aim of the current study was to better characterize indications for FGBD.

The Role of Cholecystectomy in Hyperkinetic Gallbladder: A Retrospective Cohort Study in a Rural Hospital.

Background Biliary dyskinesia is a functional gallbladder disorder in which there is an absence of a structural or mechanical cause for biliary pain. A cholecystokinin-hepatobiliary iminodiacetic acid (CCK-HIDA) scan is typically performed during workup, and cholecystectomy is the accepted treatment for low ejection fraction (EF) (less than 33%, as defined by the literature). However, few studies have examined the role of cholecystectomy in hyperkinetic gallbladder (EF ≥80%). The aim of our study was to examine symptom resolution following minimally invasive cholecystectomy in patients with hyperkinetic gallbladder. Methodology A retrospective chart review was conducted at Robert Packer Hospital in Sayre, PA. Patients who underwent minimally invasive cholecystectomy for biliary colic with EF ≥80% and who were without cholelithiasis on preoperative imaging or on final pathology were included in this study. The main outcome was symptom resolution at the postoperative visit. Data collected included age, gender, EF, body mass index, symptoms with CCK infusion, and pathology. Results A total of 48 patients were included. The mean age of patients was 41.2 years (standard deviation = 14.4), and the median age of patients was 42.2 years, with a range of 17-71 years. The majority of patients were female (83.3%). Overall, 58.3% of patients had replication of symptoms with CCK infusion. The mean gallbladder EF was 87.3%, with a median of 87.0 and a range of 80-98. In total, 33 (68.8%) patients had chronic cholecystitis on final pathology reports. There was a 95.9% symptom resolution rate among our patients two weeks postoperatively. Conclusions The overwhelming majority of patients experienced symptom resolution prior to their two-week postoperative visit following minimally invasive cholecystectomy for hyperkinetic gallbladder. These results strongly suggest a role of surgical management in patients with high EF.

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.

S3576 Oddity of an Opiated Oddi: A Case of Sphincter of Oddi Dysfunction

Introduction: We present a case of recurrent right upper quadrant (RUQ) pain resulting from Sphincter of Oddi Dysfunction (SOD) in the setting of chronic opioid use. SOD is a functional gastrointestinal disorder that presents similarly to other disorders of the biliary tree. Understanding features of this disorder and its etiologies can streamline evaluation and treatment. Case Description/Methods: Our patient is a 77-year-old male, chronic opioid user, who had multiple Emergency Department (ED) visits and hospital admissions for RUQ pain in the setting of significantly elevated liver associated enzymes (LAEs). However, repeated imaging of the RUQ with CT, Ultrasound, and MRCP remained largely unremarkable. On a subsequent presentation, the patient experienced severe increase in pain after administration of morphine. Lab investigation showed an abrupt increase in LAEs and lipase after administration of morphine. Imaging was obtained, and was again inconsistent with cholecystitis. Interestingly, he attained analgesia with meperidine on admission. During a following ED visit, RUQ imaging showed non-specific gallbladder inflammation, and a Hepatobiliary Iminodiacetic Acid (HIDA) scan showed low gallbladder ejection fraction (GBEF). These findings suggested Functional Gallbladder Disorder and laparoscopic cholecystectomy was performed. Unfortunately, ten days later the patient had worsening RUQ pain with no signs of obstruction. With diagnostic criteria for SOD met and other etiologies ruled out, our patient was referred for sphincterotomy. Discussion: Opiate-induced SOD is theoretically well known, but there have been only few reported cases in literature. Furthermore, SOD is difficult to diagnose, as providers must first rule out other hepatobiliary disease. ROME IV Diagnostic Criteria for Functional Gastrointestinal Disorders was used in review of our case. Biliary pain, absence of bile duct stones or other structural abnormalities, and elevated LAEs fulfilled the criteria for this disorder. This case highlights the clinical evaluation and care of SOD. While all opioids have been shown to contract the Sphincter of Oddi (SO), morphine has been shown to strongly cause this contraction, and is one of the earliest reported causes of SOD in literature. Meperidine has been shown to have minimal effect on the SO contraction and is the ideal opioid to treat pain of biliary or pancreatic source.

Дисфункція біліарного тракту в дітей: традиційні підходи й нові постулати

Захворюваність органів травлення в дітей посідає одне з провідних місць у структурі соматичної патології дитячого віку. Функціональні розлади біліарного тракту являють собою комплекс клінічних симптомів, що розвинулись у результаті моторно-тонічних дисфункцій жовчного міхура, жовчних проток та сфінктерного апарату жовчних шляхів. Для написання огляду здійснювався пошук даних із використанням даних Scopus, Web of Science, MedLine, PubMed, Google Scholar, CyberLeninka, РІНЦ за такими ключовими словами: біліарна дисфункція, функціональний розлад жовчного міхура, функціональний розлад сфінктера Одді, біліарна дискінезія, діти. У статті розглядаються етіопатогенетичні аспекти біліарної патології в дитячому віці. Розглянуті сучасні діагностичні та терапевтичні підходи щодо розладів жовчного міхура та сфінктера Одді в педіатричних пацієнтів у розрізі Римських критеріїв функціональних гастроінтестинальних розладів IV перегляду.

Mast cell infiltration and activation in the gallbladder wall: Implications for the pathogenesis of functional gallbladder disorder in adult patients

BackgroundFunctional gallbladder disorder (FGD) is characterized by recurrent biliary colic with a decreased gallbladder ejection fraction on cholescintigraphy but absence of visible gallbladder abnormalities on ultrasonography. FGD is generally regarded as a primary gallbladder motility disturbance, however, the underlying pathophysiology remains largely unknown. In this study, we investigated the potential role of mast cells in the pathogenesis of FGD by examining mast cell density and activation in the gallbladder wall. DesignTwenty adult patients with FGD undergoing cholecystectomy were included in the study. Seven patients with no gallbladder disease were served as controls who were subject to incidental cholecystectomy during abdominal surgery such as partial hepatectomy. The density of mast cells in the gallbladder wall was assessed by immunohistochemistry and by toluidine blue special stain. Mast cell activation was evaluated by calculating the percentage of degranulated mast cells on toluidine blue stain. ResultsCompared to the controls, patients with FGD showed a significant increase in mast cell infiltration in the gallbladder walls. Peak mast cell accumulation was predominantly located in the inner muscular layer of the gallbladder wall. Mast cell activation was also markedly increased in the FGD group as evidenced by significantly enhanced mast cell degranulation. ConclusionsMast cell infiltration and activation were significantly increased in the muscular wall of gallbladders from FGD patients, suggesting potential involvement of mast cells in the compromised gallbladder motility in adult patients with FGD.

Outcomes After Laparoscopic Cholecystectomy in Hyperkinetic Biliary Dyskinesia.

Biliary dyskinesia (BD) is a poorly understood functional gallbladder disorder. Diagnosis is made with abdominal pain and an intact gallbladder without signs of anatomical obstruction on imaging or pathology. Our aim was to assess whether laparoscopic cholecystectomy (LC) resolves hyperkinetic BD symptoms. Records of patients ≥18years of age, who underwent LC by four surgeons at a tertiary care center between 2012 and 2020, were retrospectively reviewed. Patients were excluded if they had a documented gallbladder ejection fraction (GBEF) <80% or had biliary stones or sludge on pathology or imaging. Demographic information, HIDA results, preoperative testing, operative details, gallbladder pathology, and symptom status at follow-up were collected from electronic medical records. Improvement in BD symptoms was assessed using McNemar's test. Risk differences with standard errors were employed to estimate percent reduction in symptoms. Ninety-eight patients met inclusion criteria. Of those who presented for follow-up (n = 91), 92.3% (n = 84) reported partial or complete resolution of symptoms. Preoperative symptoms, including back pain (16.7%, 95% CI: [7.9%, 25.5%]; P < .0001), epigastric pain (31.1% [21.3%, 41.3%]; P < .0001), nausea (56.7% [45.0%, 65.8%]; P < .0001), RUQ pain (57.8% [46.1%, 66.9%]; P < .0001), and vomiting (27.8% [18.4%, 37.7%]; P < .0001) showed significant improvement after LC. Chronic cholecystitis and/or cholesterolosis were present on pathology in 79.8% of gallbladders. Our study currently represents the largest cohort of patients with hyperkinetic BD. Laparoscopic cholecystectomy appears to result in resolution of symptoms for this clinical entity.

Gallbladder Disorders: A Comprehensive Review

Gallbladder disorders encompass a wide breadth of diseases that vary in severity. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of cholelithiasis-related disease, acute acalculous cholecystitis, functional gallbladder disorder, gallbladder polyps, gallbladder hydrops, porcelain gallbladder, and gallbladder cancer.

Laparoscopic Cholecystectomy for Gallbladder Dysfunction and Polyps: Incidence and Follow up.

Aim:This study aims to evaluate the incidence, indications, management, and long term follow up of cholecystectomy in patients with no gallstones, other than acalculous acute cholecystitis.Methods:Prospectively collected data of 5675 patients undergoing laparoscopic cholecystectomy (LC) over 28 years was extracted and analyzed. Patients with biliary symptoms, no stones on ultrasound scans and abnormal hepatobiliary iminodiacetic acid scans, and those with confirmed gallbladder polyps (GBP) were included.Results:Two percent of cholecystectomies were performed in patients with acalculous pathology [1.3% functional gallbladder disorder (FGBD) and 0.7% GBP]. The 114 patients were younger, had lower American Society of Anesthesiologists classification, and had fewer previous biliary admissions than those with gallstones (5560). The clinical presentations of FGBD were chronic biliary symptoms (93.1%) and acute biliary pain (6.9%). GBP patients presented with chronic biliary symptoms. LC in 98.6% FGBD and 92.8% GBP were significantly easier than those for gall stones (P < 0.0001). They were significantly (P < 0.0001 FGBD and P < 0.001 GBP) less likely to have adhesions to the gallbladder. This ease was reflected in shorter operation times and lower utilization of abdominal drains. Polyp numbers ranged from 1 to 30 and sizes from 1 mm to 11 mm. No malignant polyps were encountered. In 95.8% FGBD and 95% GBP, patients had a good symptomatic response to LC.Conclusions:FGBD and GBP are uncommon in patients undergoing LC. FGBD should be considered during evaluation of right upper quadrant pain with no gall stones. Laparoscopic cholecystectomy may be considered as it achieves long term symptomatic relief in most patients with FGBD and GBP.

Functional gall-bladder disorders and non-alcoholic fatty liver disease: clinical features and new approaches to therapy

Introduction. Statistical data indicate a frequent combination of functional biliary disorders with non-alcoholic fatty liver disease.Aim. To study the efficacy and safety of Phosphogliv® URSO in patients with functional disorders of the gall-bladder, biliary sludge in combination with fatty hepatosis in comparison with the group receiving monotherapy ursodeoxycholic acid (UDCA).Materials and methods. The study included 30 patients with a diagnosis of functional gall-bladder disorder, biliary sludge in combination with non-alcoholic fatty liver disease. Patients of the main group received monotherapy with Phosphogliv® URSO. The comparison group received monotherapy UDCA. After three-month therapy, the dynamics of clinical symptoms, laboratory parameters, and ultrasound parameters were assessed.Results. Positive dynamics of clinical manifestations of functional disorders of the gallbladder, as well as parameters of cholestatic syndrome and bilirubin level was observed in both groups. In patients taking Phosphogliv® URSO, a significant decrease in cytolysis syndrome indicators was recorded, a significant difference was revealed in relation to an increase in HDL levels and a decrease in the atherogenic coefficient in the main group. When assessing the ultrasound parameters of the gall-bladder in patients of group 1, a significant decrease in the thickness of its wall, reverse development of biliary sludge, an improvement in the contractile function of the gall-bladder in comparison with the UDCA monotherapy group were revealed.Conclusion. The use of a combined medicine containing glycyrrhizic acid and UDCA (Phosphogliv® URSO) can be recommended for patients with functional disorders of the gallbladder, biliary sludge and non-alcoholic fatty liver disease, given its more pronounced anticytolytic effect, restoration of functional disorders of the gallbladder and resolution of biliary sludge in comparison with monotherapy UDCA.

S1551 An Increasingly Common but Often Missed Diagnosis; Functional Gallbladder Disorder—A Case Report

INTRODUCTION: Functional gallbladder disorder (FGBD) is increasingly being recognized as an etiology of Biliary colics. it is characterized by typical biliary pain without an evidence of gallbladder stones, sludge or microcrystals. It is a rare disorder compared to other functional gastrointestinal (GI) disorders. it accounts for only 2% to 5% of all laparoscopic cholecystectomies. CASE DESCRIPTION/METHODS: 45 year old male presented with right upper quadrant (RUQ) pain for 1 day. Pain is progressive, colicky, 8/10 in severity with diffuse radiation, not related to food, no aggravating or alleviating factors, no associated nausea or vomiting. last bowel movement 1 day prior was formed with no blood, black stools. Patient denied fever, recent travel. He reported prior similar but less severe episode. On presentation, patient was afebrile, heart rate 104. tenderness to palpation in RUQ, negative Murphey's sign. Lab work was noted for leukocytosis 19.1 thou/mm3, normal hemoglobin and normal lipase. CT of abdomen and pelvis showed relatively decompressed GB. Ultrasonography of the RUQ showed fatty liver with no evidence of cholelithiasis, GB wall thickening nor pericholecystic fluid. Patient was started on supportive measures, however, the pain and the leukocytosis persisted for 2 days. Hepatobiliary scintigraphy was performed.it showed gallbladder ejection fraction of 3%. General surgery was consulted. robotic cholecystectomy showed dilated GB and early acute cholecystitis. After surgery, the symptoms resolved and WBCs trended down to normal range. DISCUSSION: FGBD, previously known as biliary dyskinesia, is a motility disorder, it may be due to GB muscle dysfunction or metabolic disorder that affects the mobility of the GI tract– as it is often associated with abnormal gastric emptying and colon transit- leading to ineffective bile recycling within the GB. FGBD is a diagnosis of exclusion. Hence the importance of Rome IV criteria; symptom-based diagnostic criteria in the absence of GB stones, including: RUQ or epigastric biliary pain that lasts at least 30 minutes, occurs at different intervals, severe enough to interrupt daily activities or results in emergency department visit, not related to bowel movements, and not relieved with postural changes or acid suppression. Other supportive criteria include: normal liver function, normal amylase and lipase, and low ejection fraction on scintigraphy < 35-40. it is worthy emphasizing that application of Rome IV criteria as the key for successful management.Figure 1.: 1A) Right upper quadrant ultrasound showing GB with no evidence of gallstones, gallbladder wall thickening, or pericholecystic fluid collection. 1B) CT abdomen/pelvis without contrast showing a relatively decompressed gallbladder.Figure 2.: Hepatobiliary scintigraphy w/ ejection fraction with Cholecystokinin stimulation showing 2A) GBEF at 10 minutes = 1%, 2B) GBEF at 20 minutes = 4%, 2C) GBEF at 30 minutes = 3%.

An interdisciplinary approach to the problem of gallstone disease in women: a view of a gynecologist

The article presents the modern view on pathogenetic mechanisms of the cholelithiasis development in women, illustrated by clinical observations. Gender-associated risk factors for cholelithiasis are pregnancy and childbirth, female sex hormones administration and polycystic ovary syndrome. The gallstone disease risk factors in women taking hormonal oral contraceptives and menopausal hormone therapy are hereditary predisposition, impaired lipid, carbohydrate metabolism and functional gallbladder disorders. Patients at high risk of developing cholelithiasis are recommended to perform a gallbladder ultrasound examination before and during hormonal therapy. The ursodeoxycholic acid treatment is safe, effective and compatible with female sex hormone administration in patients with detected biliary sludge.