Abnormal gallbladder nuclear ejection fraction predicts success of cholecystectomy in patients with biliary dyskinesia

doi:10.1016/S0002-9610(05)80677-4

The American Journal of Surgery

Volume 166, Issue 6, December 1993, Pages 672-675

https://doi.org/10.1016/S0002-9610(05)80677-4 Get rights and content

The management of patients with symptoms consistent with biliary tract disease who do not have gallstones is difficult. We retrospectively reviewed the charts of 18 patients who underwent cholecystokinin cholescintigraphy at our institution to determine if this procedure was reliable in identifying patients who would benefit from cholecystectomy. All patients underwent biliary screening, and a gallbladder ejection fraction of less than or equal to 35% was considered abnormal. None of the patients had evidence of gallstones by ultrasound. There were 11 patients with abnormal ejection fractions. All 11 patients (100%) had “classic” biliary colic and underwent cholecystectomy. The pathologic diagnosis was chronic cholecystitis in every patient. All patients had complete relief of their symptoms postoperatively with a mean follow-up of 10 months. There were six patients with normal ejection fractions. Only one patient in this group had “classic” biliary colic. This patient had a gallbladder ejection fraction of 38% and endoscopic evidence of gastritis. This patient remains symptomatic despite H₂ blockade. The remaining five patients had nonspecific right upper quadrant or epigastric pain. These patients had endoscopic evidence of gastritis, and symptoms were relieved with H₂ blockade. The remaining patient had an indeterminate scan due to radioactivity in the duodenum overlying the gallbladder and was excluded from this analysis. Cholecystokinin cholescintigraphy is a useful test in identifying those patients with biliary dyskinesia or acalculous cholecystitis who will benefit from cholecystectomy.

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Cited by (85)

Biliary hyperkinesia, a new diagnosis or misunderstood pathophysiology of dyskinesia: A case report
2019, International Journal of Surgery Case Reports
Biliary colic, characterized by intermittent right upper quadrant abdominal pain is a common complaint in the United States population. Patients whose pain is undiagnosed by ultrasound generally undergo hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (HIDA-CCK) to assess function of the gallbladder and biliary tree. Traditionally, two outcomes are possible based on a measured ejection fraction of the gallbladder: either dyskinesia or normal function is diagnosed. Biliary dyskinesia, or hypokinesia of the gallbladder, is accepted as an ejection fraction less than 35%, while an accepted normal functioning gallbladder ejection fraction is greater than 35%.
We report a case of a fifteen-year-old female who had functional gallbladder disease per Rome IV criteria due to intermittent biliary colic, with exception to the ejection fraction measurement which was elevated at 96.5%. She underwent laparoscopic cholecystectomy with complete symptom resolution.
As demonstrated in the literature reviewed here, these subsets of patients, who present with normal to high ejection fractions, have undergone laparoscopic cholecystectomy with resolution of pain in several case studies.
Many unknown variables still exist due to lack of prospective studies, most notably the pathophysiology and definitive indications for surgical treatment. As such, we propose that surgical options should not be limited to those who display the traditional findings of biliary dyskinesia, but also patients who demonstrate typical symptoms with normal to elevated ejection fraction, following work up to rule out the extensive differential diagnoses for right upper quadrant abdominal pain.
Effects of laparoscopic cholecystectomy in normokinetic biliary dyskinesia
2018, American Journal of Surgery
Citation Excerpt :
Caution against the use of surgical intervention in this subset of patients was advised.12,13 Since then, there has been a multitude of studies looking at acalculous biliary disease with symptom resolution following cholecystectomy (47–100%) versus employing conservative management (0–91%).6,10,11,14–39 Unfortunately, the majority of these studies are retrospective in nature with small study populations.
This is the largest single center retrospective study to date looking at response to laparoscopic cholecystectomy in patients with acalculous biliary disease. A chart review was completed on 1116 patients from 2009 to 2014 who had admitting diagnoses related to acalculous cholecystitis and biliary colic. Four hundred and seventy four patients were available for long term follow up (6 months or longer). Multiple factors were studied as related to cholescintigraphy scans with cholecystokinin administration (HIDA with CCK). Hyperkinetic, normokinetic and hypokinetic ejection fractions (EF), as well as reproduction of symptoms with administration of CCK were catagorized. ROME III criteria (Table 1) were used to describe cholecystitis/biliary colic symptoms. (1).
It was found that rates of resolution of symptoms after laparoscopic cholecystectomy in normokinetic and hypokinetic were similar. It was also found that reproduction of symptoms after administration of CCK was a better predictor of favorable response to surgery than calculated ejection fraction.
Biliary Dyskinesia
2008, Surgical Clinics of North America
Functional disorders of the biliary tract include gallbladder dyskinesia (GBD) and sphincter of Oddi dysfunction (SOD). The diagnosis of GBD is made if the gallbladder ejection fraction is less than 35% to 40% using cholecystokinin cholescintigraphy. Despite slightly inferior outcomes compared with calculous disease, patients who have GBD should be treated with cholecystectomy. SOD is most often noted in the postcholecystectomy patient and symptoms can be biliary or pancreatic in nature. The gold standard for diagnosis remains manometry, with basal biliary or pancreatic sphincter pressures measuring greater than 40 mm Hg. Patients who have increased pressures may benefit from endoscopic sphincterotomy.
The role of <sup>99m</sup>technetium-labelled hepato imino diacetic acid (HIDA) scan in the management of biliary pain
2007, HPB
Objective. To assess the outcome of laparoscopic cholecystectomy on the basis of an abnormal provocative ^99mtechnetium-labelled hepato imino diacetic acid (HIDA) scan for patients with typical biliary pain and normal trans-abdominal ultrasound (TUS) scan. Patients and methods. Prospective data were collected for 1201 consecutive patients with typical biliary symptoms. Patients who were found to have a normal TUS and upper GI endoscopy subsequently underwent cholescintigraphy (HIDA scan). Patients with an abnormal HIDA scan, i.e.<40% ejection fraction with Sincalide® (cholecystokinin octapeptide) – were offered cholecystectomy. Symptoms and histology were reviewed postoperatively. Results. In all, 48/1201 (4%) patients with typical biliary symptoms had a normal ultrasound and endoscopy; 35/48 patients had an abnormal provocative HIDA scan and all underwent laparoscopic cholecystectomy. Histology in all cases revealed chronic cholecystitis and 18 patients had sludge or microlithiasis within the gallbladder. At 6-week follow-up, 31 of the 35 patients were completely asymptomatic or improved. Furthermore, 79% of patients remained symptom-free or improved at a median follow-up of 28.5 months (range 4–70). Conclusions. HIDA scan is a useful clinical tool as an adjunct to the diagnosis and management of patients who present with typical biliary pain and a normal TUS scan.
Sincalide-stimulated cholescintigraphy a retrospective study and proposal of a modified workflow
2022, Clinical Nuclear Medicine
Biliary hyperkinesia: an indication for cholecystectomy?
2021, Surgical Endoscopy

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^†: Presented at the 45th Annual Meeting of the Southwestern Surgical Congress, Monterey, California, April 18–21, 1993.

¹: From the Department of Surgery, University of Arkansas for Medical Sciences, Little Rock Arkansas.

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Abnormal gallbladder nuclear ejection fraction predicts success of cholecystectomy in patients with biliary dyskinesia†

Gastroenterology

Gastroenterology

Results of surgical therapy for biliary dyskinesia

Arch Surg

Cholecystokinin cholescintigraphy: detection of abnormal gallbladder motor function in patients with chronic acalculous gallbladder disease

J Nucl Med

Gallbladder ejection fraction: a decade of progress and future promise

J Nucl Med

Cholecystokinin (CKK) functional cholescintigraphy (FC) in patients suspected of acalculous biliary disease

J Nucl Med