Understanding the Biliary Dyspepsia / 대한췌담도학회지

Functional dyspepsia is a very common disease and there are two types of dyspepsia. One is functional dyspepsia in the gastrointestinal tract and the other is pancreatobiliary dyspepsia. Biliary dyspepsia is caused by biliary tract disease and can even cause biliary pain. Acalculous biliary pain (ABP) is biliary colic without gallstones, it is caused by functional biliary disorder or structural disorders such as microlithiasis, sludges or parasitic infestation like Clonorchiasis. The endoscopic ultrasonography is helpful tool for differential diagnosis of ABP. Although sphincter of Oddi manometry (SOM) is performed for the confirmative diagnosis of sphincter of Oddi dysfunction (SOD), several non-invasive tests have been studied because of some practical limitations and invasiveness of SOM itself. In fact, the most clinically used easy test to diagnose functional biliary disorder is quantitative hepatobiliary scintigraphy and it can distinguish gallbladder dyskinesia, SOD, or combined type. Initial treatment of functional biliary disorder is adequate dietary control and medication, but if the symptoms worsened or recurred frequently, laparoscopic cholecystectomy could be performed with gallbladder dyskinesia. If SOD is suspected, additional SOM should be considered and endoscopic sphincterotomy (EST) can be done according to the outcome. If the SOM is not available, the patient could be diagnosed by stimulated ultrasound.

Fatty meal sonography comparing coconut oil and chocolate bar with full-fat yoghurt as cholecystagogues for gallbladder ejection fractions

Background: The authors compared the effectiveness of a chocolate bar and full-fat yoghurt combination to coconut oil in determining the gallbladder ejection fraction (GBEF). The clinical motive was functional gallbladder disorder (FGD) which has the clinical picture of symptomatic gallstones but without gallstones. Functional gallbladder disorder has a decreased GBEF of less than 35%. Gallbladder ejection fraction can be calculated by ultrasound, using cholecystokinin (CCK) as a stimulant for gallbladder contraction. Cholecystokinin is not available in South Africa, and the researchers compared a 60 g Snickers chocolate bar with 200 g full-fat yoghurt, against the theoretically superior coconut oil. Objectives: To determine the efficacy of coconut oil versus chocolate bar and 200 g full-fat yoghurt combination in performing sonographic GBEFs. Method: This was a randomised clinical experiment, before and after crossover trial. The three experimental components of the study included 15 g coconut oil, 20 g coconut oil and a standard fatty meal consisting of 60 g Snickers bar and 200 g full-fat yoghurt. Results: The GBEF for the chocolate bar and yoghurt combination was the highest (62.84%). The GBEF for 20 g of coconut oil was 23.47% and for 15 g of coconut oil was 5.11%. There was a statistically significant difference between the chocolate and yoghurt combination and the 20g coconut oil, as well as the chocolate yoghurt combination and the 15 g coconut oil, both with a p-value of < 0.0001. No statistically significant difference was found between the 20 g and 15 g coconut oil. Conclusions: The 60 g Snickers chocolate bar and 200 g full-fat yoghurt combination was superior to the coconut oil. The authors advocate using the chocolate and yoghurt fatty meal oral stimulant to determine GBEF

Discinesia da vesícula biliar / Gallbladder dyskinesia

A dor abdominal é um sintoma relativamente comum que leva centenas de pessoas (adultos e crianças) aos centros de emergência e consultórios médicos no Brasil e no mundo. Eventualmente, a investigação por anormalidades estruturais nos órgãos abdominais não revela alterações indicativas de doença, resultando no diagnóstico de desordem funcional gastrointestinal. As desordens funcionais precisam ser investigadas a fundo para a aquisição do diagnóstico correto e início do tratamento direcionado. Nas últimas cinco décadas, a Discinesia da Vesícula Biliar (DVB) tem sido reconhecida como a principal causa da dor abdominal em pacientes com desordens funcionais gastrointestinais sem alterações aparentes nos órgãos abdominais. A DVB é um distúrbio funcional da vesícula biliar caracterizada pelos sintomas de cólica biliar, pela ausência de patologia da vesícula biliar visível e pela redução da fração de ejeção da vesícula biliar (FEVB) observada na colecintigrafia. Entretanto, o diagnóstico e o tratamento desta doença permanecem controversos. Nesse contexto, o presente trabalho consiste em uma revisão da literatura e tem, como objetivo, apresentar e discutir o estado da arte da DVB, contemplando as mais atuais modalidades de diagnóstico e os principais métodos de tratamento da doença.

The abdominal pain is a relatively common symptom that takes hundreds of people (adults and children) to Emergency Rooms and doctors offices in Brazil and all around the world. Occasionally, the search for structural irregularities in the abdominal organs does not reveal indication of diseases, leading to the diagnosis of gastrointestinal functional disorder. The functional disorders must be deeply investigated in order to achieve the correct diagnosis and begin the specific treatment. Over the last five decades, the Gallbladder Dyskinesia (GD) has been recognized as the main cause for abdominal pain among patients with gastrointestinal functional disorders but no apparent alteration in the abdominal organs. The GD is a gallbladder functional disorder known for symptoms such as biliary colic, absence of any noticeable gallbladder pathology and a reduction of the gallbladders ejection fraction (GEF) noticed through the cholecystography. Nonetheless, the diagnosis and the treatment for this disease remain controversial. In this context, the following study consists in a review of the literature and has, as its main objective, to present and discuss the current situation of the GV, addressing the most advanced diagnosis strategies and the main treatment methods for the disease.

Regional Differences in Hospitalizations and Cholecystectomies for Biliary Dyskinesia

BACKGROUND/AIMS: Published studies suggest that socioeconomic factors contribute to increasing cholecystectomy rates for biliary dyskinesia (BD). The aim of this study was to identify factors driving admissions and operations for BD by examining regional variability in hospitalizations and cholecystectomies for this disorder. METHODS: Annual hospitalizations and cholecystectomy rates for biliary diseases were assessed using the State Inpatient Databases of the Agency for Healthcare Research and Quality based on diagnosis codes for biliary dyskinesia, cholecystolithiasis and cholecystitis. RESULTS: Annual admissions for BD varied nearly sevenfold among different states within the United States. Hospitalizations for gallstone disease and its complication showed less variability, differing 2-fold between states. Nearly 70% of admissions for BD and about 85% of admissions for gallstone disease resulted in cholecystectomies. Higher admission rates for BD were best predicted by high overall hospitalization rates, admission rate for gallstone disease and the physician workforce within a state. Cholecystectomy rates for BD were higher in states with low population density and high rates of cholecystectomy for gallstone disease. CONCLUSIONS: These data suggest that established medical practice patterns significantly contribute to the variability in admissions and operations for biliary dyskinesia. The findings also indicate that lower thresholds for operative interventions are an important determinant in the approach to this disorder. Considering the benign course of functional illnesses, the bar for surgical interventions should be raised rather than lowered; in addition active conservative treatment options should be developed for these patients.

Hallazgos anatomopatológicos en pacientes con disfunción biliar / Pathological findings in patients with biliary dysfunction

Se efectuó un estudio descriptivo, transversal y retrospectivo de 84 pacientes atendidos en el Servicio de Gastroenterología del Hospital General Docente D Juan Bruno Zayas Alfonso de Santiago de Cuba desde enero de 2010 hasta igual mes de 2011, a los cuales se realizó colecistectomía por presentar manifestaciones clínicas de disfunción biliar; pero después de extirparles la vesícula, acudieron a la consulta externa de la especialidad con dolor abdominal y cuadros diarreicos, entre otros síntomas y signos. En busca de datos más precisos, se comparó el diagnóstico preoperatorio con los hallazgos anatomopatológicos, de donde se derivó que a pesar de que en muchos casos no coincidían, ello no obstaculizó la obtención de resultados satisfactorios en los integrantes de la casuística.

A descriptive, cross-sectional, and retrospective study with 84 patients assisted at Gastroenterology Service from Dr Juan Bruno Zayas Alfonso General Teaching Hospital in Santiago de Cuba was carried out from January, 2010 to January, 2011. These patients underwent a colecistectomy for having clinical manifestations of biliary dysfunction. After removing the gallbladder, patients having abdominal pain and diarrhea, among other symptoms and signs, attended the outpatient department related to this speciality. Searching for precise data, the pre-surgical diagnosis was compared to the pathological findings, in which case it was concluded that, in spite of many cases did not match, this fact did not hinder the obtaining of satisfactory results in the case material.

The Comparison of Medical and Surgical Treatment for Gallbladder Dyskinesia

PURPOSE: The purpose of this study was to compare outcomes for surgical treatment with those for medical treatment of GB dyskinesia. METHODS: Retrospective analysis of medical records and telephone interviews of 67 patients diagnosed with GB dyskinesia was done at Pohang St. Mary's Hospital between January 2004 and December 2009. Group 1 (n=18) patients received laparoscopic cholecystectomy. Group 2 (n=49) patients received medical treatment. GB dyskinesia was the diagnosis if the patient had typical biliary colic symptoms without GB stones or other GI disease, and if the ejection fraction was less than 35% on Tc-99m-DISIDA scans. RESULTS: The average age of patients diagnosed with GB dyskinesia was 45.8 years old. The sex ratio was 15:52 (male:female). The average symptom duration was 25.4 days. All had RUQ and, or epigastric pain. There were no significant between group differences in age, sex ratio, symptom duration, symptoms, follow up period, and ejection fraction. In group 1, patient symptoms improved after treatment in 16 cases (88.9%); in group 2, patient symptoms improved in 19 cases (38.8%). Surgical treatment was significantly more effective than medical treatment. The reasons for choosing medical treatment were predominantly the preference of the doctors. CONCLUSION: Surgical treatment is a more effective treatment for GB dyskinesia than medical treatment. Therefore, laparoscopic cholecystectomy should be considered as the 1st line treatment of choice for GB dyskinesia.

Percutaneous Transhepatic Biliary Manometry / 대한소화기학회지

Perendoscopic biliary manometry may not represent the overall sphincter of Oddi (SO) motility, as the recording time is relatively short and it is possibly influenced by the presence of an endoscope in duodenum and air inflation. Percutaneous transhepatic biliary manometry of SO permits long-term recordings without patient discomfort and risk of complications. We investigated the change of human SO motility and the correlation between SO motility and migrating motor complex (MMC) of the small bowel in a fasting state by long-term simultaneous manometric examination of SO and small bowel. During long-term manometry, MMC-like cyclic activities of SO were observed, which consiered to be MMC of SO. It coordinated well with MMC of the small bowel, except that SO was not quiescent during phase I MMC of the small bowel. In addition, the basal pressure of SO changed in accordance with the phases of SO motility. Percutaneous transhepatic biliary manometry also permits prolonged manometric studies to investigate normal physiologic reflexes such as gastroduodeno-sphincteric, cholecysto-sphincteric and choledocho-sphincteric reflexes, and the influence of cholecystectomy on SO motility in humans.

Evaluation of biliary dyskinesia in diabetic patients with and without autonomic neuropathy and factors affecting it

Diabetes mellitus is known as one of the factors causing the cholesterol gallstone. Though the pathophysiologic mechanisms of this phenomenon are unclear, hypotheses such as reduced gallbladder motility were presented to explain the higher incidence of gallstones in diabetes. The aim of our study was to study gall bladder motor function in diabetic patients with and without autonomic neuropathy to reach the pathogenesis of gallbladder dysfunction in diabetic patients and to correlate GB dyskinesia with demographic features [Age, sex, BMI Body Mass index and waist to hip ratio], duration of illness, fasting and two hours post-prandial blood glucose levels, lipogram and type of antihyperglycemic drugs. Our study included fifty persons, 30 type 2 diabetic patients divided into two groups, group [A] included 15 patients with autonomic neuropathy and group [B] included 15 patients without autonomic neuropathy, and 20 age matched healthy persons. All studied groups were subjected to the following: Careful history and clinical examination, measurement of body weight, height, and BMI. Measurement of waist circumference and hip circumference, calculation of waist/hip ratio and assessment of Cardiovascular autonomic function by the bedside tests of Ewing et al. [1985], which are: Heart rate response to standing, heart rate response to Valsalva maneuver, heart rate response to deep breathing, systolic blood pressure response to standing, diastolic blood pressure response to sustained hand grip. Fasting and two hours post-prandial blood glucose levels with follow up for 3 months, liver function tests, lipogram, blood urea and serum creatinine. Abdominal ultrasonograhy and Tc99m hepato-immuno-diacetate hepatobiliary scintigraphy after 6 hours fasting and 30 minutes after fatty meals for 30 minutes to measure the gallbladder ejection fraction. The results of our study revealed that GBEF was lower in type 2 diabetic patients in comparison with the control group. It was also found that GREF was lower in diabetic patients with autonomic neuropathy than in those without. In our study we discovered that GBEF was lower in type 2 diabetic patients with autonomic neuropathy than in those without and there is inverse correlation between GBEF and fasting and after two hours blood glucose levels. We did not find any correlation between the duration of diabetes mellitus and GBEF probably because of the small sample of patients with long duration and no correlation was found between GBEF and demographic features or lipogram. Furthermore, we did not find a significant correlation between GBEF and the type of antihyperglycemic drugs

Role of hepatobiliary scintigraphy in the evaluation and management of post-cholecystectomy pain due to biliary dyskinesia.

Imaging with technetium-99m analogs of imminodiacetic acid has been shown to be useful in the diagnosis of various hepatobiliary diseases. The biliary ductal dilatation is usually late response of obstruction. With the development of TC-99m IDA scintigraphy, however, the functional aberrations associated with obstruction can be detected prior to the development of ductal enlargement identifiable by US & CT. We report a case of post-cholecystectomy pain due to biliary dyskinesia diagnosed by 99m TC-HIDA hepatobiliary imaging.

Diabetic autonomic neuropathy causing gall bladder dysfunction.

OBJECTIVE: The objective of the study was to study gall bladder volume in fasting and 45 minutes post-prandial, by real time ultrasound in healthy controls and diabetic patients with and without autonomic neuropathy and to compare them. METHOD: Age, Sex and body mass index (BMI) matched 50 healthy subjects and 10 patients with insulin dependent diabetes mellitus and 40 patients with noninsulin dependent diabetes mellitus were evaluated according to National diabetes Data Group of National Institute of Health (1979) criteria: 1. Fasting (overnight) venous plasma glucose concentration of > 140 mg/dl on two separate occasions. 2. Following ingestion of 75 gms of glucose, venous plasma glucose concentration of > 200 mg/dl at second hour and at one other occasion during two hour test. Autonomic neuropathy was assessed by the presence of symptoms like dysphagia, abdominal fullness, nausea, vomiting, diarrhea +/- nocturnal, faecal incontinence or constipation, dysuria, urinary incontinence, the gustatory sweating, impotence etc. and were confirmed by standing test for orthostatic hypotension, hand grip test, Valsalva test and deep breaths test. RESULT: The study showed that: 1. Patients of diabetes mellitus had statistically significant larger fasting gall bladder volumes and these values were highly significant amongst patients with autonomic neuropathy. 2. Patients of diabetes mellitus and statistically significant larger post fatty meal gall bladder volume and these values were highly significant in patients with autonomic neuropathy. CONCLUSIONS: We therefore conclude that impaired gall bladder contraction was found amongst patients of diabetes mellitus with autonomic neuropathy. The mechanism responsible for cholecystoparesis is attributed to vagal neuropathy. Incomplete gall bladder emptying leads to sequestration of cholesterol and nidus formation. Therefore gall bladder functions should be evaluated routinely in such patients and early intervention is recommended.

Manometría endoscópica del esfínter de Oddi / Endoscopic manometry of sphincter of Oddi

Background: Endoscopic manometry is the gold standard for the diagnosis of sphincter of Oddi dysfunction. Aim: To report the result of the first 30 endoscopic manometries of sphincter of Oddi performed in a Gastroenterology Service. Patients and methods: Thirty manometries were performed in 28 patients aged 30 to 70 years old (14 females). The papilla was cannulated with a perfused catherter, measuring pressure with external transducers. Results: Deep cannulation of the papilla was achieved in 88 por ciento. Procedure-related complications were not observed in these cases. Normal values were registered in 11 cases with a basal sphincter pressure 15.6ñ10.7 mm Hg, contractions with an amplitude of 92.3ñ35.7 mm Hg and 6.0ñ2.4/ min frequency. The clinical suspicion suspicion of hypertonic dyskinesis was confirmed in 5 cases with an elevated basal pressure of 43.69ñ13.3 mm Hg, an increased frequency of contractions ("tachyoddia") in one, and large spastic contractions of high pressure in other case. In 3 of 5 cases with common bile duct stones, a predominance of retrograde propagation of the contractions was observed with normal pressure. Variable manometric results were observed after endoscopic papillotomy observing a scale from the complete absence of motor activity to normal aphincter function. Conclusions: Endoscopic manometry is a reasonably safe method, of great importance in the diagnosis of fuctional disorders of the sphincter of Oddi

Trastornos motores del sistema biliar en la infancia: presentacion de 5 pacientes / Motor disorders of the biliary tract in childhood: report of 5 cases

En la infancia el dolor abdominal recurrente es muy frecuente, y en algunas ocasiones no es posible encontrar la causa. Con el proposito de elucidar en parte este problema, se decidio estudiar los trastornos motores del sistema biliar en la infancia como posibles causas de estos cuadros. Se realizo un estudio prospectivo en el Hospital Pediatrico Docente "San Miguel del Padron", de 1989 a 1994 de todos aquellos ninos con dolor abdominal recurrente y sin una causa especifica. Se uso ultrasonografia y colecistografia oral con vaciamiento cronometrado y se encontraron 5 pacientes en quienes se pudo realizar esos diagnosticos. El mas frecuente fue la vesicula biliar hipertonica e hipercinetica en 2 pacientes a quienes se les efectuo una colecistectomia; el resto tuvo una evolucion satisfactoria sin intervencion quirurgica. Se sugiere debido a los resultados obtenidos, que estos trastornos deben ser tenidos en cuenta en el estudio de pacientes con dolor abdominal recurrente

Clinical Indications for Biliary Drainage Procedures

Inspite of the benign disease process, the management of intrahepatic duct stones is difficult because of complications such as recurrent ascending cholangitis, liver abscess, sepsis, secondary liver cirrhosis, cholangiocarcinoma, and high recurrence rates. Also they are sometimes difficult to remove completely due to their anatomical locations. The principles of their surgical management are composed of complete removal of the stone and prevention of biliary stasis. The commonly used biliary drainage procedures are transduodenal sphincteroplasty, choledochoduodenostomy, and Roux-en-Y choledochojejunostomy. The results of biliary drainage procedures in 82 patients at the Department of Surgery, Taejon St. Mary's Hospital, from January 1985 through December 1994 were reviewed, including a follow-up study. The incidence of biliary drainage procedures, including hepatic resections, was 18.9% of the 433 patients operated on for cholelithiasis. The male- to- female ratio was 1 : 1.5; the sixth decade was the most common age. The common clinical symptoms and physical signs were right upper quadrant and epigastric pain and tenderness (89.0%), jaundice (56%), and fever and chills (47.4%). Fifty-six percent of the cases involved the first incidence of a biliary operation, 34.1% a second incidence, and 9.7% a third. The biliary stones were located at only the intrahepatic area (31.7%), both the intrahepatic and the extrahepatic areas (35.3%), or both the gall bladder and the extrahepatic area (29.0%). Of the intrahepatic stones, the left lobe was involved in 45.5% of the cases, the right lobe in 9%, and both lobes in 45.5%. The indications for biliary drainage procedures were acute obstructive cholangitis (36.5%), recurrent stones (34.1%), biliary dyskinesia (21.9%), and liver abscess (7.3%). The types of biliary drainage procedures were choledochoduodenostomy (43.9%), Roux-en-Y choledochojejunostomy (21.9%), left hepatic lobectomy (14.6%), left lateral hepatic segmentectomy (8.5%), Roux-en-Y hepaticojejunostomy (8.5%), right hepatic lobectomy (1.2%), and transduodenal sphincteroplasty (1.2%). The early postoperative complications were wound infection (24.3%), pulmonary complications (19.5%), anastomosis leakage (2.4%), etc. The operative mortality was 1.2%. The late complications during the follow-up period were recurrent stones (11 cases), ascending cholangitis (8 cases), and liver abscess (5 cases).

Avaliaçäo da atuaçäo do ácido dehidrocólico na funçäo da vesícula bibliar / Therapeutic evolution of dehydrocolic acid (B-Vesil) at gallbladder discinesy

Foi feito um acompanhamento de 10 pacientes com uso do ácido dehidrocólico (B-Vesil), que apresentavam problemas de discinesia biliar. Estes pacientes foram acompanhados com exames complementares os quais demonstraram uma boa resposta ao estímulo de esvaziamento da vesícula biliar

Gall bladder dysmotility in diabetes mellitus--an ultrasound study.

Fifty two diabetic patients and 15 healthy control subjects were prospectively studied for their gall bladder function by ultrasound examination. The fasting gall bladder volume (FGBV) was calculated by using ellipse formula from the dimension of gall bladder shadow seen on ultrasound screen in two different cuts. The contractility of gall bladder was measured by calculating post prandial ejection fraction (EF) of the gall bladder. The mean FGBV and EF in 52 diabetic patients was found to be 20.7 +/- 10.7 cc and 47.5 +/- 20.1%, which was not significantly different from that in normal controls. Age, sex, obesity, diabetic control and presence of dyspeptic symptoms had no impact in FGBV and EF. Diabetic symptoms had no impact in FGBV and EF. However, diabetics with longer duration of disease had poorer gall bladder contractility (p < 0.05). Patients with autonomic neuropathy (AN) had significantly larger FGBV but normal contractility. Our results suggest that (a) long standing diabetics may have poor gall bladder emptying predisposing to gall stone formation (b) patients with autonomic neuropathy have reduced tone of fasting gall bladder but normal contractility.

Reproducibility of Percutaneous Sphincter of Oddi Manometry / 대한소화기내시경학회지

To assess the reproducibility of Sphincter of Oddi(SO) manometry, percutaneous manometry of SO was performed repeatedly in 10 subjects with biliary diseases(9 intrahepatic stone cases and 1 bile duct cancer case). Time interval for measurement of SO manometry was 3 to 7(mean 5) days. Mean manometric parameters of SO phasic contraction in the 1st and 2nd studies were not significantly different. However, as a result of manometric records, a diagnosis of dyskinesia was made in the 1st study from 4 patients(tachyoddia in 3 cases and increased retrograde propagation in one case). Among them, the diagnosis was reproduced in the 2nd study from 2(tachyoddia in 2 cases) out of 4 patients. In conclusion, abnormal manometric findings were poorly reproducible. Thus, more prolonged measurement of SO manometry or a dynamic test which stimuli or inhibit the SO activity may be necessary for accurate diagnosis of biliary dyskinesia and better reproducibility of SO manometry.

Colecistografia oral retardada (modificada) no estudo da discinesia biliar / Oral cholecystography delayed (modified) to the study of biliary dyskinesia

A discinesia infundíbulo-colo-cística, ou discinesia biliar, traz dificuldades no seu diagnóstico e na sua conduta terapêutica. Estudamos uma modificaçäo da colecistografia oral onde se objetiva adequá-la ao estudo daquela patologia ou doença. Fez-se a colecistografia oral clássica complementada por radiografias após 24 e 48 horas. Julgamos que a retençäo do contraste apos 48 horas merece um estudo melhor da vesícula, até para possível indicaçäo cirúrgica

Radiologic Diagnostic Criteria of Sphincter of Oddi Dysfunction: Analysis of Five Cases Confirmed by Biliary Manometry

PURPOSE: Biliary dyskinesia was considered as a wastebasket of quasi-biliary disease which could not be clearly explained under the basis of morphologic pathology. This entity was a source of confusion because of misconception and poor understanding. Recent introduction of biliary manometric technique enlightened some of these disorders. We evaluated the cholangiographic morphology of these disorders to clarify and to characterize the some characteristic findings, subsequently in order to help the diagnosis. MATERIALS AND METHODS: Five cases were confirmed by this technique as sphincter of Oddi dysfunction for last 13 months. All patients were female and age range was 53 to 75 years old. All patients were suffered from intermittent and recurrent biliary type pain. RESULTS: ERCP showed five common findings. The common bile duct was dilated over 12ram in all patients. Different from recurrent pyogenic cholangiohepatitis, intrahepatic ducts were proportionally dilated as extrahepatic ducts, in four patients and they branched normally and ductal wall was smooth. Transient or persistent meniscus sign was observed in four patients. All patients showed delayed emptying of contrast media from the common bile duct into the duodenum. Following IV injection of cholecystokinin, persistent meniscus disappeared and contrast media inflowed into the duodenum. CONCLUSION: Identification of all or some characteristic cholangiographic findings may eliminate a cumbersome and painful biliary manometric test for the diagnosis of sphincter of Oddi dysfunction.