Biliary Dyskinesia

DEFINITION
Functional Biliary Dysfunction
Note that the clinically-similar condition of Sphincter of Oddi dysfuction (paradoxical contraction spasm causing similar pain) can be readily differentiated by HIDA scan.
- it is not discussed further here.
Originally reported by Whipple (1926) as a series of 47 patients who did not have evidence of cholelithiasis despite typical biliary symptoms, yet in whom 75% were relieved of their pain.

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EPIDEMIOLOGY
Any age
Most common indication for cholecystectomy in children.
Possibly more common in females.
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AETIOLOGY
Functional impairment of gallbladder.
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BIOLOGICAL BEHAVIOUR

Pathogenesis

Cystic duct stricture possible
Areas of investigation include:
- intrinsic gallbladder muscle dysfunctional
- CCK receptor function

Associations
These pts have a higher incidence of other GI motility problems as well (Tabet, 1999).
- ie GORD, colonic inertia, IBS, gastric paresis.
- may explain why many do not get great relief after lap chole.
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MANIFESTATIONS
A subgroup of pts with typical biliary colic symptoms and signs.
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INVESTIGATIONS

Imaging
USS
Typically conducted in these pts with biliary symptoms but found to be normal.

Gastroscopy

Similarly is usually a right-of-passage to getting a HIDA scan to rule out peptic cause.

HIDA scan
CCK-Tc-HIDA scan.
CCK is infused for 3mins intravenously after GB filled with 99Tc-labeled radionuclide.
Calculates the gallbladder ejection fraction.
<35% at 20mins is considered abnormal.
- this was delineated by work by Fink-Bennet et al.
- statistically correlated with symptom resolution and pathological evidence of chronic cholecystitis in most.

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MANAGEMENT

Operative
Lap chole.
Important to inform pt of chances of symptom resolution from following:
- 85-94% of pts show improvement or become asymptomatic (Sabiston)
- review (1998, Canfield et al) of 200 reported cases showed 81% become asymptomatic and further 15% improved.
- confirmed by later addition of 27 pts with 89% significantly and 7% partly improved (1999, Yost)
Longer term outcomes may be worse than short term.

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REFERENCES
Sabistons 17th.
Canfield et al. J Gastrointest Surg 1998;2:443-8.
Yost et al. Am J Surg 1999;178:462-5.
Tabet et al. Surg Laparosc Endosc Percut Tech. 1999;9:382-6.
Fink-Bennett et al. J Nucl Med 1991;32:1695-9.
ANZ J Surg 2002;72:731-4.