A 44-year-old woman with a history of endometriosis who underwent total abdominal hysterectomy/bilateral salpingo-oophorectomy and appendectomy complains of intermittent right upper-quadrant pain of 3-4 on a 10-point scale for the past month. I suspect she has biliary dyskinesia, but she is able to sleep and has no nausea, vomiting, or diarrhea. A low-fat diet has resulted in a 10-lb weight loss, with no symptomatic improvement. Lab studies, including an SMA, complete blood count, erythrocyte sedimentation rate, and amylase and lipase determinations, were within normal limits. Ultrasound, CT, and magnetic resonance cholangiopancreatography were negative. No stones were observed in the gallbladder or ducts. Endoscopy with biopsies was negative. There is no evidence of Helicobacter pylori. A colonoscopy has been scheduled. Her hepatobiliary iminodiacetic acid ejection fraction is low (<20%). Is there any conservative treatment for biliary dyskinesia? Is laparoscopic cholecystectomy a reasonable option?
—Holly W. Pomeranz, DO, West Palm Beach, Fla.
Biliary dyskinesia, or functional gallbladder disorder, is often a diagnosis of exclusion. The ROME criteria for diagnosis are well established (Gastroenterology. 2006;130:1498-1509). Patients typically present with moderate-to-severe episodic right upper-quadrant or upper abdominal pain that interrupts their daily activities or prompts a visit to an emergency department and lasts 30 minutes or more (among other criteria). Nausea or vomiting and nocturnal symptoms are supportive but not necessary, so these don't rule out the diagnosis in this case. A workup to exclude structural abnormalities or more classic stone disease is warranted in patients who meet the ROME III criteria. This includes, as you have done, measuring gallbladder ejection fraction induced via cholecystokinin at cholescintigraphy.
Conservative treatment options are limited, and no large trials exist. Some studies have shown mixed results using nitrates or sustained-release nifedipine, but these involved small numbers of patients in a nonrandomized fashion (Gastroenterology. 1988;95:1050-1055 and Dig Dis Sci. 1996;41:1814-1818). Cholecystectomy is rapidly becoming the treatment of choice. A meta-analysis examined five studies, with cumulative data in 274 patients showing 90% symptomatic relief with operative treatment vs. 32% symptomatic relief in nonoperative treatment arms (J Laparoendosc Adv Surg Tech A. 2005;15:439-442).
—Christopher Ruser, MD (120-14)