Gallbladder Ejection Fraction Research Articles

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.

Gall bladder ejection fractions in dogs investigated for chronic altered appetite: 14 cases (2015-2017).

To determine if gall bladder dysmotility occurs in dogs investigated for chronic altered appetite and to determine if gall bladder dysmotility warrants further investigation as a contributing factor to altered appetite. Case series of dogs investigated for chronic gastrointestinal disease. Gastrointestinal clinical signs were assessed before and after a 6-week hydrolysed protein diet. Gall bladder ejection fractions were determined at the end of the 6-week hydrolysed protein diet as part of an investigation that included a full blood cell count, biochemistry, abdominal X-rays and ultrasound. The gall bladder ejections fraction results of dogs with normal appetite were compared to dogs with general inappetence and dogs with diurnal inappetence in the morning. In this retrospective case series of 14 dogs, altered appetite was the most frequent and persistent clinical sign associated with chronic gastrointestinal disease. Nine dogs had suboptimal gall bladder function and this occurred in dogs with, and without, gravity-dependent biliary sludge. Gall bladder function and volumes of dogs in this study were comparable to those of dogs with nongravity-dependent gall bladder sludge or gall bladder mucoceles in other studies. There was an observable difference in gall bladder ejection fractions between groups defined by appetite but no statistically significant difference was present. Small sample sizes meant the effect size was large. Gall bladder dysmotility and distension can occur in the absence of gall bladder sludge and mucocoeles in younger dogs. Gall bladder dysmotility requires further investigation as a potential contributing factor to altered appetite in dogs.

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.

Pediatric Gallbladder Dysmotility: Not as Rare as Previously Considered; a Case Report and Review of Literature

Introduction: Chronic abdominal pain in children is mostly functional, but in association with alarm symptoms such as recurrent vomiting, it is necessary to determine proper tests for the diagnosis of probable underlying organic problems. Case Presentation: Four patients with chronic refractory abdominal pain and nonspecific gastrointestinal symptoms presented to our tertiary pediatric center. After thorough medical and psychological investigations and hepatobiliary scintigraphy, and calculating gallbladder ejection fraction, laparoscopic cholecystectomy was performed. One year after the surgery, they were relatively symptom-free and returned to their routine life. Conclusions: Biliary tract abnormalities should be considered as a probable cause of chronic abdominal pain in children. Hepatobiliary scintigraphy can provide promising results to help to identify the underlying causes of chronic abdominal pain in association with nonspecific gastrointestinal manifestations.

1215-P: Effects of Exogenous Secretin on Postprandial Plasma Glucose and Lipids and Gallbladder Motility and Hemodynamics in Man

Secretin is best known for its effect on pancreatic exocrine secretion. It also has osmoregulatory effects and was recently identified as a potential target for the treatment of obesity. We investigated the effects of a 5-hour intravenous (iv) secretin infusion on postprandial plasma glucose and lipids and gallbladder motility as well as hemodynamics in healthy males. In a randomized, double-blind, placebo-controlled, crossover study, 25 healthy males (25.7 ± 6.1 (mean ± SD) years; BMI 23.4 ± 1.8 kg/m2) underwent two 5-hour iv infusions of secretin (1 pmol/kg/min) or placebo (saline), with an interposed 8-week washout period. After 30 minutes of infusion, a standardized liquid mixed meal was ingested. Prior to and with regular intervals during the 5-hour infusions, blood samples were drawn, ultrasonography of the gallbladder performed, and hemodynamics measured. Steady-state plasma concentrations of secretin amounted to 113 ± 2 pmol/L, i.e., ~20-fold higher than physiological levels. Postprandial plasma triglyceride excursions were higher during secretin than placebo infusions (baseline-subtracted area under curve: 111 ± 49 vs. 83 ± 36 min × pmol/L [P = 0.012]), whereas excursions in glucose, glycerol and free fatty acids were similar during placebo and secretin infusions. Compared to placebo, secretin reduced maximum gallbladder ejection fraction by 32 ± 27% (P <0.001) and increased mean systolic and diastolic blood pressure by 5.3 ± 4.5 (P <0.039) and 2.2 ± 3.2 mmHg (P <0.001), respectively, and increased heart rate by 5.5 ± 3.6 bpm (P <0.001). We conclude that a 5-hour iv infusion of secretin in healthy males has no effect on fasting and postprandial glucose levels, but reduces postprandial gallbladder contraction, while increasing plasma triglycerides, blood pressure and pulse. Disclosure M. J. Bentzen: None. S. M. Nguyen heimbürger: Speaker’s Bureau; Self; AstraZeneca. B. Hartmann: None. J. J. Holst: Consultant; Self; Novo Nordisk, Other Relationship; Self; Antag Therapeutics, Bainan Biotech, MSD Corporation, Novo Nordisk, Other Relationship; Spouse/Partner; Antag Therapeutics, Bainan Biotech, Synklino ApS. M. B. Christensen: None. F. K. Knop: Advisory Panel; Self; MSD Corporation, Novo Nordisk A/S, Sanofi, Consultant; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Eli Lilly and Company, Novo Nordisk A/S, Pharmacosmos, Zealand Pharma A/S, Research Support; Self; Novo Nordisk A/S, Zealand Pharma A/S, Speaker’s Bureau; Self; AstraZeneca, Bayer AG, Boehringer Ingelheim Pharmaceuticals, Inc., Eli Lilly and Company, MSD Corporation, Novo Nordisk A/S.

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.

A pediatric surgeon's dilemma: does cholecystectomy improve symptoms of biliary dyskinesia?

Biliary dyskinesia (BD) is a well-established gallbladder pathology in adult patients and rates of cholecystectomy for BD continue to rise in the United States. Many pediatric patients with vague abdominal pain of variable duration are evaluated for biliary dyskinesia. It remains unknown which cohort of pediatric patients diagnosed with BD are most likely to have sustained improvement in symptoms following laparoscopic cholecystectomy. We aimed to determine whether cholecystectomy resulted in symptom relief and led to a reduction in the number of medical visits related to gastrointestinal (GI) symptoms after surgery. We performed a multi-institution retrospective review of all children < 18 years of age who underwent laparoscopic cholecystectomy for BD between January 2013 and April 2018 in our hospital system. GI symptoms and clinical visits related to a GI complaint were assessed preoperatively. Patients were followed for 2 years after surgery. At 6 months and 2 years postoperatively, symptoms and the rate of medical visits related to a GI complaint were quantified and compared to the preoperative values. In total, 45 patients met our inclusion criteria. Of these, 82% of patients were female. The average age was 14 years old (± 2.6) and 56% of patients met the criteria for being overweight or obese. The mean gallbladder ejection fraction was 13% (± 10.8). All patients had abdominal pain, 82% (37/45) presented with nausea, and 51% (23/45) presented with post-prandial pain. Six months postoperatively, 58% of patients experienced resolution of their abdominal pain which decreased to 38% of patients after 2 years. Similarly, 59% had resolution of their nausea at 6 months compared to 43% at 2 years, and 100% had resolution of their post-prandial pain at 6 months compared to 91% at 2 years. The total number of clinical visits related to a GI complaint decreased from 2.6 (± 2.4) preoperatively to 1.0 (± 1.3) within 6 months postoperatively. When followed to 2 years postoperatively, the 6-month rate of clinical visits related to a GI complaint decreased from a mean of 2.6 preoperatively to 0.71 following surgery. Following cholecystectomy, we observed a high percentage of durable symptom resolution in those patients with BD who presented with post-prandial pain. Patients with non-food-related abdominal pain, with or without nausea and vomiting, had a lower rate of symptom resolution after surgery and the rate declined with time. For patients without post-prandial pain, evaluation and treatment of alternative sources of pain should be considered prior to surgery. Regardless of their presenting symptoms, patients who underwent surgery for BD had fewer clinical GI-related visits after surgery. However, no specific gallbladder ejection fraction or symptom alone was predictive of a lower rate of clinical visits postoperatively.

Clinical characteristics and histology of cholecystectomised dogs with nongravity-dependent biliary sludge: 16 cases (2014-2019).

To report the available histology, biochemistry and clinical progression of dogs without classic overt biliary tract signs that underwent cholecystectomy for nongravity-dependent biliary sludge. Case series of client-owned dogs for which a cholecystectomy was performed for nongravity-dependent biliary sludge. In six dogs, for which nongravity-dependent biliary sludge filled less than half of gall bladder volume, gall bladder ejection fractions were measured. Available histology, biochemistry, presenting clinical signs and post-surgical clinical progression were reported. Sixteen dogs were included in this retrospective case series. No dogs met the histological criteria for gall bladder mucocoeles or had histological evidence of primary hepatitis or cholangitis. Biochemistry was normal for 11 dogs. Hypercholesterolaemia was not noted in any dog. Twelve dogs had cholecystitis (11 lymphoplasmacytic, one neutrophilic) and nine dogs had biliary mucosal hyperplasia. Thirteen dogs had enteritis (12 lymphoplasmacytic, one eosinophilic) and nine dogs had reactive hepatitis (eight lymphoplasmacytic, one neutrophilic). All six dogs with nongravity-dependent biliary sludge that filled less than half of gall bladder volume had sub-optimal gall bladder function. Presenting clinical signs, including diurnal inappetence in the morning and exercise intolerance, resolved in 86% (12/14) of dogs after cholecystectomy and clinical improvement was noted in 81% (13/16) of dogs overall. Duodenal inflammation could potentially impact gall bladder dysmotility in dogs with nongravity-dependent biliary sludge. Furthermore, diurnal inappetence in the morning and exercise intolerance could indicate symptomatic gall bladder disease in dogs with NDBS and can potentially precede more obvious systemic clinical signs associated with gall bladder mucocoeles.

Acupoint Catgut Embedding as Adjunctive Therapy for Patients With Gallstones.

Aims of This Study:A randomized clinical trial was undertaken to investigate the efficacy of acupoint catgut embedding (ACE) as adjunctive therapy to tauroursodeoxycholic acid (TUDCA) therapy on gallbladder emptying and clinical symptoms in patients with gallstone disease.Materials and Methods:Between August 2018 and January 2019, 70 patients with gallstones in our hospital were enrolled in this prospective clinical trial. All the patients were randomly divided into the ACE group (ACE+TUDCA treatment for 8 wk) and the Sham group (Sham ACE+TUDCA treatment for 8 wk). In the ACE group, all the patients were nightly given ACE every 2 weeks, and in 2 groups, every patient took TUDCA 500 mg at bedtime. The parameters about gallbladder emptying were detected by ultrasound before and after the treatment, and the clinical symptom scores were recorded at the same time points.Results:A total of 63 patients with gallstone disease were included in our study, with 33 patients in the ACE group and 30 patients in the Sham group. In the ACE group, the empty volume (EV) and gallbladder ejection fraction (GBEF) were improved after treatment (P<0.05). Almost every symptom score (except symptom 7, P=0.15) and total score were decreased (P<0.05). In the Sham group, the symptom 1, 2, 4, 5 scores, and total score were significantly decreased (P<0.05). Moreover, the residual volume in the ACE group was significantly lower than in the Sham group (P=0.008). The EV and GBEF in the ACE group were higher than that in the Sham group (P<0.05). The score of symptom 6 in the ACE group was lower than that in the Sham group (P=0.008).Conclusion:ACE therapy could more effectively improve the gallbladder emptying with a shorter treatment course. Therefore, ACE+TUDCA therapy might be a time-saving treatment for gallstones.

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.

Gallbladder motility in children with celiac disease before and after gluten-free diet.

BackgroundGallbladder (GB) hypomotility has been reported in adults with celiac disease (CD), but there is no literature on GB dysfunction in children with CD. We aimed to study GB motility in children with CD, before and after a gluten-free diet (GFD), using ultrasonography (USG) and technetium-99 labeled mebrofenin hepatobiliary scintigraphy (HBS).MethodsChildren with newly diagnosed CD were enrolled and evaluated for GB ejection fraction (GBEF) using HBS and USG. Those with reduced GBEF on initial HBS were again evaluated after 6 months of strict GFD and the results were compared.ResultsOf the 50 children with CD (mean age 9±2.1 years, 54% boys), 16% (n=8) had a low GBEF at baseline (19±13%). These children had a significantly greater delay in diagnosis compared to those with normal GBEF (6.5±2.0 vs. 2.3±1.2 years, P<0.001). A significant improvement in GBEF was noted on HBS post GFD (74±12%1 vs. 9±13%, P<0.001). GBEF also improved significantly as assessed by USG parameters after GFD (P<0.001). The fasting GB volume decreased (5.7±1.4 vs. 10.2±2.6, P=0.002), with a significant improvement in percentage postprandial GB volume change (52±10.5% vs. 24±16.5%, P=0.007) compared to baseline pre-GFD values. Orocecal transit time was also increased in children with reduced GBEF.ConclusionsGB function is impaired in at least 16% of children with CD at diagnosis and is reversible with GFD. GB dysfunction is significantly associated with a delayed diagnosis and may be a part of general gastrointestinal dysmotility.

Relations between Hepatobiliary Scintigraphy Findings and Histopathological Factors in Patients with Recurrent Biliary Colic

Background: The histopathological factors of gallbladder that affect the findings of hepatobiliary scintigraphy is not fully known. The aim of the present study is to investigate the relationship between hepatobiliary scintigraphy findings and histopathological results in patients with recurrent biliary colic. Methods: A total of 107 patients who underwent hepatobiliary scintigraphy for recurrent biliary colic and subsequent cholecystectomy were retrospectively enrolled. According to the hepatobiliary scintigraphy findings, patients were categorized into three groups; patients with non-visualization of gallbladder activity (non-visualized GB group), gallbladder ejection fraction (GBEF) of < 35% (low GBEF group), and GBEF of ≥ 35% (normal GBEF group). Results: Of all patients, 31 patients were classified as non-visualized GB group, 33 were low GBEF group, and 43 were normal GBEF group. Non-visualized group showed higher rates of patients with severe neutrophil, lymphoplasma cell, and eosinophil infiltrations and empyema and showed more increased cystic duct wall thickness than other groups (p< 0.05). Low GBEF group showed higher muscle-to-total wall thickness ratio and muscle-to-fibrosis thickness ratio than those with normal GBEF group (p< 0.05). On multivariate logistic regression analysis, Severe degrees of lymphoplasma cell infiltration (p=0.027) and eosinophil infiltration (p< 0.001) were independent predictors for non-visualization gallbladder activity, and muscle-to-fibrosis thickness ratio (p=0.030) was an independent predictor for low GBEF. Conclusions: In patients with recurrent biliary colic, non-visualization of gallbladder activity on hepatobiliary scintigraphy was related with the degree of inflammation in the gallbladder, while GBEF was related with muscular hypertrophy of the gallbladder.

Biliary Dyskinesia: Current Perspectives and Future Directions.

Biliary dyskinesia (BD) is a disorder characterized by functional biliary pain, the absence of gallstones on ultrasound, and the finding of a reduced gallbladder ejection fraction on a cholecystokinin-cholescintigraphic scan. Cholecystectomy remains a commonly applied treatment for BD, despite a lack of high-quality evidence supporting the practice. The following article provides an overview of the current diagnostic strategies, treatment outcomes with both surgical and nonsurgical treatment, emerging considerations related to special populations, and suggestions for addressing the identified knowledge gaps, moving forward in an effort to develop stronger, more evidence-based practice guidelines for treating this poorly understood and poorly studied condition.

Optimal hepatobiliary scintigraphy for gallbladder dyskinesia

BackgroundThe accuracy of hepatobiliary scintigraphy to assess gallbladder function remains controversial. National supply shortages of pharmaceutical-grade cholecystokinin led to the use of an oral fatty meal to stimulate gallbladder contraction during hepatobiliary scintigraphy. The goal of this study was to compare the predictive indices of cholecystokinin and fatty meal ingestion for stimulation of gallbladder contraction. MethodsPatients evaluated with hepatobiliary iminodiacetic acid scan from 2014 to 2017 were reviewed and grouped based on testing stimulant (fatty meal versus cholecystokinin). Patients who later underwent cholecystectomy were selected for analysis. Hepatobiliary iminodiacetic acid results were correlated with surgical pathology and postoperative resolution of symptoms. Two-way statistical analysis was performed. ResultsA total of 359 patients underwent hepatobiliary iminodiacetic acid scan followed by cholecystectomy for biliary dyskinesia. Patients who received fatty meal stimulant (n = 86) were compared to those that received cholecystokinin (n = 273). Mean gallbladder ejection fraction during hepatobiliary iminodiacetic acid was 38% and 44% for the cholecystokinin and fatty meal groups, respectively, P = .073. Predictive metrics were not statistically different between groups with regard to pathology, symptomatic improvement, or accuracy. Symptomatic resolution (cholecystokinin–hepatobiliary iminodiacetic acid 78%, fatty meal–hepatobiliary iminodiacetic acid 68%; P = 0.058) and specificity (cholecystokinin–hepatobiliary iminodiacetic acid 26%, fatty meal–hepatobiliary iminodiacetic acid 44%, P = 0.417) were comparable in both testing groups. ConclusionStimulation of gallbladder contraction with a fatty meal during hepatobiliary iminodiacetic acid testing is a more affordable and reliable alternative to cholecystokinin for patients undergoing evaluation for gallbladder dysmotility.

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.

Sonographically determined clues to the symptomatic or silent cholelithiasis.

To determine an association between sonographically determined contractility with the symptomatic or silent nature of gallstone. Designing: Comparative, cross-sectional study. Radiology Department, Dow University of Health Sciences (DUHS) and Civil Hospital, Karachi (CHK), from April 2004 to March 2005. Adult gallstone patients without (group I) and with biliary symptoms (group II) were compared with age and gender-matched controls. Demographic data, body mass index, risk factors, size, number and mobility of gallstone, gallbladder wall thickness (GBWT), volume and Ejection Fraction (EF) were determined on ultrasound before and after a standardized fatty meal (BFM and AFM). Demographic data, risk factors and gallstone characteristics were analyzed by Pearson Chi-square test and the gallbladder characteristics were analyzed by One-way ANOVA and Post Hoc tests by multiple comparisons on SPSS 11 with significance p=0.05. The gallbladder contractility as measured by changes in wall thickness and volume changes BFM and AFM, and ejection fraction was similar in controls and asymptomatic cholelithiasis groups and significantly reduced in symptomatic patients (p < .001). Multiparity (p=0.002), female gender (p=0.018), age less than 50 years (0.05), impacted calculi (p=0.001), multiple calculi (< .001) and calculi 5mm (p < 0.001) were associated with pain. A sluggishly emptying gallbladder was more significantly associated with symptomatic cholelithiasis compared to controls and asymptomatic cholelithiasis state in this series. Consideration of age, gender, impaction of calculi, number and size of calculi is important in causing symptom state and management options.

Litholytic agents as an alternative treatment modality in patients with biliary dyspepsia.

Biliary dyspepsia presents as biliary colic in the absence of explanatory structural abnormalities. Causes include gallbladder dyskinesia, sphincter of Oddi dysfunction, biliary tract sensitivity, microscopic sludges, and duodenal hypersensitivity. However, no consensus treatment guideline exists for biliary dyspepsia. We investigated the effects of medical treatments on biliary dyspepsia.We retrospectively reviewed the electronic medical records of 414 patients who had biliary pain and underwent cholescintigraphy from 2008 to 2018. We enrolled patients who received litholytic agents and underwent follow-up scans after medical treatment. We divided the patients into the GD group (biliary dyspepsia with reduced gallbladder ejection fraction [GBEF]) and the NGD group (biliary dyspepsia with normal GBEF). We compared pre- and post-treatment GBEF and symptoms.Among 57 patients enrolled, 40 (70.2%) patients had significant GBEF improvement post-treatment, ranging from 34.4 ± 22.6% to 53.8 ± 26.8% (P < .001). In GD group (n = 35), 28 patients had GBEF improvement after medical treatment, and value of GBEF significantly improved from 19.5 ± 11.0 to 47.9 ± 27.3% (P < .001). In NGD group (n = 22), 12 patients had GBEF improvement after medical treatment, but value of GBEF did not have significant change. Most patients (97.1% in GD group and 81.8% in NGD group) had improved symptoms after medical treatment. No severe complication was reported during treatment period.Litholytic agents improved biliary colic in patients with biliary dyspepsia. Therefore, these agents present an alternative treatment modality for biliary dyspepsia with or without gallbladder dyskinesia. Notably, biliary colic in patients with gallbladder dyskinesia resolved after normalization of the GBEF. Further prospective and large-scale mechanistic studies are warranted.

Biliary hyperkinesia: an indication for cholecystectomy?

The main indications for laparoscopic cholecystectomy are stone-related diseases in adults. With a normal abdominal ultrasound (US), a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. Biliary dyskinesia or low gallbladder EF (EF < 35%) is a recognized indication for cholecystectomy. Recent articles report long-term resolution of symptoms in children with high EFs on the HIDA scan. The purpose of this study is to evaluate the response of patients with biliary colic and hyperkinetic gallbladder to cholecystectomy. We suggest that laparoscopic cholecystectomy might be a considerable surgical option in a subset of the adult population whose workup for food-related biliary abdominal pain is negative except for the high-value EF on HIDA scan. Data were consecutively collected from all patients who underwent laparoscopic cholecystectomy between June 2012 and June 2019 at a single institution. Cases were identified using Current Procedural Terminology codes. Patients older than 17years of age with the negative US (no stone, no sludge, no gallbladder wall thickening) and EF greater than 80% on cholecystokinin (CCK)-HIDA scan were included in this study. All patients were seen at 2weeks and 10-16months after surgeries. Over 7years from June 2012 until June 2019, of 2116 patients who underwent laparoscopic cholecystectomy, 59 patients (2.78%) met study criteria. Postprandial abdominal pain was the most common symptom (43, 72.90%) followed by nausea/vomiting. Forty-seven patients (74.6%) had a reproduction of symptoms with CCK infusion. The average EF was 88.51%. Final pathology showed chronic cholecystitis in 41 (69.5%) patients, cholesterolosis in 13 (22%), polyp in 2 (3.4%). Thirty-six (61%) patients had complete resolution of symptoms, 9 (15%) patients had partial resolution, and 14 (24%) patients had no change. There was a complete resolution rate of 61% and an improvement rate of 76%. In patients with biliary symptoms, negative ultrasound, and elevated EF on HIDA scan (EF > 80%), laparoscopic cholecystectomy led to a significant rate of symptomatic relief. Interestingly, 94% also had unexpected pathologic findings. This disease process requires further analysis, but this could represent a new indication for laparoscopic cholecystectomy in the adult population.

Cholescintigraphy may have a role in selecting patients with biliary dyskinesia for cholecystectomy: a systematic review.

Patients with typical biliary pain, no gallstones on ultrasound and low gallbladder ejection fraction (GBEF) on cholescintigraphy (gallbladder dyskinesia) may be considered for a laparoscopic cholecystectomy. However, some studies have suggested that symptoms alone are an adequate indication for laparoscopic cholecystectomy. The aim was to determine the role of cholescintigraphy in predicting outcomes of cholecystectomy in patients with typical and atypical biliary symptoms and normal biliary ultrasound. Meta-analysis using Preferred Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines of published literature using several electronic databases. Twenty-four articles were selected with a total of 1710 patients. The majority (n = 1633, 94.4%) of patients had typical biliary symptoms. A total of 1047 patients with typical symptoms and a reduced GBEF had a cholecystectomy with 852 (81.4%) having complete resolution of symptoms. A total of 148 with typical symptoms and normal GBEF had a cholecystectomy with 103 (69.5%) having complete resolution, which was significantly less than those with a reduced GBEF (odds ratio 1.65, confidence interval 1.08-2.05, P = 0.01). Forty-five patients with atypical symptoms and a reduced GBEF had a cholecystectomy with 31 (68.9%) having complete resolution of symptoms, which is significantly lower than those with typical symptoms (odds ratio 1.97, confidence interval 0.95-3.90, P = 0.05). Cholescintigraphy improved the predication of outcome of cholecystectomy in biliary dyskinesia by 10%. However, the presence of typical symptoms does predict an effective response in 70% of patients. Atypical symptoms predict a poorer response.

Relations between hepatobiliary scintigraphy findings and histopathological factors in patients with recurrent biliary colic.

The aim of the present study was to investigate the relationship between hepatobiliary scintigraphy findings and histopathological results in patients with recurrent biliary colic. We retrospectively enrolled 107 patients who underwent hepatobiliary scintigraphy for recurrent biliary colic and subsequent cholecystectomy. According to the hepatobiliary scintigraphy findings, patients were categorized into a nonvisualization of gallbladder activity (nonvisualized GB) group, low gallbladder ejection fraction (GBEF) group, and normal GBEF group. Differences in histopathologic factors between the three groups were evaluated and multivariate logistic regression analyses were performed to identify histopathological predictors for hepatobiliary scintigraphy findings. The nonvisualized group had a higher frequency of patients with empyema and severe infiltration by neutrophils, lymphoplasma cells, and eosinophils. The low GBEF group had a higher muscle-to-total wall thickness ratio and muscle-to-fibrosis thickness ratio of the gallbladder wall than those in the normal GBEF group. On multivariate logistic regression analyses, severe degrees of lymphoplasma cell infiltration and eosinophil infiltration were independent predictors for nonvisualization of gallbladder activity, and a higher muscle-to-fibrosis thickness ratio was an independent predictor for low GBEF. In patients with recurrent biliary colic, nonvisualization of gallbladder activity on hepatobiliary scintigraphy was related to the degree of inflammation in the gallbladder, while low GBEF was related to muscular hypertrophy of the gallbladder.