Reduced Gallbladder Ejection Fraction Research Articles

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.

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.

Functional Gallbladder Disorder

Objective: To shed light on the clinical presentation and approach to diagnosis. Introduction: Functional gallbladder disorder is a dysfunction in gallbladder motility, the exact etiology remains unclear. As in all gastrointestinal motility disorders the diagnosis of functional gallbladder disorder is a diagnosis of exclusion. It is estimated that 21% of females and 8% of males with biliary-like pain and a normal transabdominal gallbladder ultrasound have functional gallbladder disorder. Case: A 30 year old Caucasian female with no significant past medical history presented with recurrent right upper quadrant (RUQ) pain. The pain has been persistent for several months and was associated with nausea and vomiting. The patient was recently diagnosed with a small gastric ulcer for which she was taking dexlansoprazole. Despite taking the medication as prescribed for a month, her symptoms were not alleviated. The patient continued to have pain that interfered with her daily activities and resulted in multiple visits to the emergency room (ER) where she was treated symptomatically. On her last visit to the ER the patient had a typical biliary-type pain, her physical exam was positive for RUQ pain, but Murphy's sign was negative. Initial work up including liver and pancreas blood tests were normal. Transabdominal gallbladder ultrasound revealed no cholelithiasis, sludge or signs of acute cholecystitis. CT abdomen was unimpressive as well. The patient was admitted to the hospital to control her symptoms and to further investigate the cause of the pain. The Gastroenterology service was consulted and the patient was scheduled to undergo cholecystokinin (CCK)-stimulated cholescintigraphy. The cholescintigraphy revealed decreased appearance of gallbladder activity and a reduced gallbladder ejection fraction (GBEF) of 34%, subsequently the patient was diagnosed with functional gallbladder disorder and she underwent cholecystectomy. The patient's symptoms significantly improved after surgery. Conclusion: In the case of typical biliary-like pain, normal blood work and normal transabdominal gallbladder ultrasound, clinicians should have a high index of suspicion for functional gallbladder disease.

Cholecystectomy alleviates acalculous biliary pain in patients with a reduced gallbladder ejection fraction.

We sought to determine whether a reduced gallbladder ejection fraction, (GBEF) ascertained by cholecystokinin-cholescintigraphy (CCK-CS), predicts symptomatic improvement after cholecystectomy. Medical records of patients who had had CCK-CS as well as negative results of gallbladder ultrasonography were reviewed, and patients were contacted by telephone to determine whether they had benefited from cholecystectomy. There were 35 patients (33 female, 2 male) who had a decreased GBEF. Cholecystectomy was done in 30, of whom 20 (67%) had resolution of pain, 8 (27%) had partial improvement, and 2 (7%) had no change. The 5 who declined cholecystectomy included none (0%) who were pain free, 2 (40%) who had partial improvement, and 3 (60%) who had no change. The clinical outcome of the two groups was significantly different. There were 14 patients (10 female, 4 male) with a normal GBEF. The 2 patients who had cholecystectomy were asymptomatic. Of the 12 patients who did not have cholecystectomy, 9 (75%) were asymptomatic, 1 (8%) had some improvement, and 2 (17%) had no change. Cholecystectomy is indicated for patients with acalculous biliary pain and reduced GBEF, since symptoms will likely resolve with surgery and will persist without it. Cholecystectomy for patients with a normal GBEF should be considered only after failure of a nonoperative trial, since improvement usually occurs over time.

Cholescintigraphy in acalculous biliary pain: if abnormal, should cholecystectomy follow?

A 45–minute infusion of an octapeptide of cholecystokinin (Kinevac; Squibb Diagnostics, New Brunswick, NJ) was used to measure the gallbladder ejection fraction during cholescintigraphy in 40 normal volunteers. Cholecystokinin cholescintigraphy was shown to be a reproducible test. The maximum mean gallbladder ejection fraction occurred 15 minutes after cholecystokinin infusion and was 74.5% ± 1.9% (mean ± SEM). A gallbladder ejection fraction &gt;40% (mean - 3SD) was arbitrarily defined to be normal. The gallbladder ejection fraction test was then used to identify patients with acalculous biliary symptoms who may respond to cholecystectomy. A total of 103 patients was tested; 21 had abnormal gallbladder ejection fractions and were randomized into two groups, cholecystectomy or no operation. These patients were followed up symptomatically at 3–month intervals for 13-54 months (mean, 34 months). Of the 11 patients who underwent cholecystectomy, 10 (91%) lost their symptoms and 1 improved. Of the 10 patients in the group that did not undergo surgery, all continued to be symptomatic, 2 of whom requested cholecystectomy after 13 and 24 months, respectively. Of the 13 gallbladders obtained from surgery, 12 showed evidence of chronic cholecystitis, muscle hypertrophy, and/or narrowed cystic duct. A normal gallbladder ejection fraction was recorded in 82 patients, and further treatment was left to the discretion of their referring clinician. On follow–up, 50 patients were asymptomatic and 10 were symptomatic without specific treatment of the biliary tract; 14 underwent cholecystectomy, 8 of whom were asymptomatic. Pathological abnormalities were recorded in 6 of the removed gallbladders. It is concluded that the gallbladder ejection fraction obtained after a 45–minute infusion of cholecystokinin during cholescintigraphy is a reproducible measure of gallbladder emptying, and that cholecystectomy alleviates the biliary–type pain of patients with a reduced gallbladder ejection fraction.

Acalculous biliary pain: Cholecystectomy alleviates symptoms in patients with abnormal cholescintigraphy

A 45-minute infusion of an octapeptide of cholecystokinin (Kinevac; Squibb Diagnostics, New Brunswick, NJ) was used to measure the gallbladder ejection fraction during cholescintigraphy in 40 normal volunteers. Cholecystokinin cholescintigraphy was shown to be a reproducible test. The maximum mean gallbladder ejection fraction occurred 15 minutes after cholecystokinin infusion and was 74.5% ± 1.9% (mean ± SEM). A gallbladder ejection fraction > 40% (mean − 3SD) was arbitrarily defined to be normal. The gallbladder ejection fraction test was then used to identify patients with acalculous biliary symptoms who may respond to cholecystectomy. A total of 103 patients was tested; 21 had abnormal gallbladder ejection fractions and were randomized into two groups, cholecystectomy or no operation. These patients were followed up symptomatically at 3-month intervals for 13–54 months (mean, 34 months). Of the 11 patients who underwent cholecystectomy, 10 (91%) lost their symptoms and 1 improved. Of the 10 patients in the group that did not undergo surgery, all continued to be symptomatic, 2 of whom requested cholecystectomy after 13 and 24 months, respectively. Of the 13 gallbladders obtained from surgery, 12 showed evidence of chronic cholecystitis, muscle hypertrophy, and/or narrowed cystic duct. A normal gallbladder ejection fraction was recorded in 82 patients, and further treatment was left to the discretion of their referring clinician. On follow-up, 50 patients were asymptomatic and 10 were symptomatic without specific treatment of the biliary tract; 14 underwent cholecystectomy, 8 of whom were asymptomatic. Pathological abnormalities were recorded in 6 of the removed gallbladders. It is concluded that the gallbladder ejection fraction obtained after a 45-minute infusion of cholecystokinin during cholescintigraphy is a reproducible measure of gallbladder emptying, and that cholecystectomy alleviates the biliary-type pain of patients with a reduced gallbladder ejection fraction.

SCINTIGRAPHIC DETECTION OF COMMON BILE DUCT (CBO) OBSTRUCTION

The purpose of the study was to critically assess the role of Tc-99m-IDA scintigraphy in 25 patients with either partial (n=14) or complete (n=11) CBD obstruction and to correlate results with the cholangiogram. After a minimum 4 hour fast, each patient received 3 to 8 mCi of Tc-99m-IDA intravenously and the serial hepatobiliary images were obtained at 2 minute intervals for 60 minutes and at 3 and 24 hours when needed. Nine patients with partial CBO obstruction received OP-CCK for quantitative assessment of biliary dynamics. Scintigraphically, the partial CBD obstruction was characterized by either segmental narrowing or intraluminal filling defect (13/14), intrahepatic bile pooling in area and segmental ducts (7/14) and markedly reduced gallbladder ejection fraction (8/9) and ejection rate (6/9). The obstruction was distal in 8, mid to distal in 5 and the level of obstruction correlated well with Rholangiogram. Complete CBD obstruction was characterized by relatively good hepatic uptake but no secretion into bile of Tc-99m-IDA resulting in total non-visualization of entire biliary system (including GB and CBD) and small intestine in 10 of 11 patients. CBD was faintly seen in one patient. Localization could not be made in any with complete CBD obstruction. It is concluded that Tc-99m-IDA scintigraphy is an accurate test for detection of CBD obstruction and localization can be accomplished in partial but not total CBD obstruction. Thus scintigraphy may service as an ideal non-invasive screening test in assessing CBD obstruction.