Cholecystectomy for Biliary Hyperkinesia.

Patients with classic biliary colic symptoms and documented gallbladder ejection fractions on the higher end of the spectrum on hepatobiliary iminoacetic acid scans with cholecystokinin stimulation are presently understudied and the benefits of cholecystectomy are unclear. To determine whether patients with biliary-type pain and biliary hyperkinesia (defined as a gallbladder ejection fractions of 80% or greater) benefit from laparoscopic cholecystectomy, a retrospective chart review encompassing five community hospitals was performed. Patients 16 years and older with diagnosed biliary hyperkinesia who underwent laparoscopic cholecystectomy between January 1, 2010 and May 31, 2015 were included. Pathology reports were reviewed for histologic changes indicating cholecystitis. Resolution of biliary colic symptoms was reviewed one to three weeks after surgery in their postoperative follow-up documentation. Within our study cohort, we found 97 patients who underwent laparoscopic cholecystectomy for biliary hyperkinesia. Within this population, 84.5 per cent of patients undergoing laparoscopic cholecystectomy for biliary hyperkinesia had positive findings for gallbladder disease on final pathology. Of the 77 patients with data available from their first postoperative visit, 70 (90.9%) reported improvement or resolution of symptoms. Our findings suggest that symptomatic biliary hyperkinesia may be treated successfully with surgery.

An Update on Biliary Dyskinesia.

Biliary dyskinesia is a functional disorder of the gallbladder or sphincter of Oddi. While cholecystectomy for symptomatic cholelithiasis is widely accepted, debate remains regarding the clinical benefit of invasive procedures for biliary dyskinesia. This article will review current best evidence in the diagnosis and management of biliary dyskinesia.

Is hyperkinetic gallbladder an indication for cholecystectomy?

BACKGROUND: The (99m) technetium-labelled hepato imino diacetic acid (HIDA) scan is widely used to evaluate patients with biliary colic with a normal trans-abdominal ultrasound scan. Most studies recommend cholecystectomy for patients with biliary dyskinesia, defined by gallbladder ejection fraction (GBEF) of less than 35-40% on HIDA scan. There are no recommendations regarding management of hyperkinetic gallbladder defined by GBEF of greater than 80% on HIDA scan. The aim of our study was to evaluate the outcomes following cholecystectomy on patients with biliary colic associated with hyperkinetic gallbladder. METHODS: We performed a retrospective chart review of all patients with biliary colic associated with hyperkinetic gallbladder that underwent cholecystectomy in our practice from July 2014 to February 2018. Data collection included age, gender, body mass index, preoperative symptoms, comorbidities, additional tests, ejection fraction, surgery, and histopathology of the gallbladder. Symptomatic improvement was assessed during routine 2-week postoperative visit and a follow-up phone interview. RESULTS: Thirty-two patients had undergone laparoscopic cholecystectomy during the study period for symptomatic hyperkinetic gallbladder. All the patients had abdominal pain related to food intake and 17 (53%) patients had worsening of symptoms with CCK infusion. The average GBEF was 92%. Chronic cholecystitis was seen in 29 (90%) patients on pathology. 23 (74%) patients had complete resolution of biliary symptoms, 5 (16%) had improved symptoms, and 3 (10%) had no change in symptoms. CONCLUSION: Patients with biliary colic and hyperkinetic gallbladder respond favorably to laparoscopic cholecystectomy. Our results suggest that patients with biliary colic in the setting of hyperkinetic gallbladder have symptomatic improvement following cholecystectomy.

An update on the pathogenesis of cholesterol gallstone disease.

PURPOSE OF REVIEW: Gallstone disease is a major epidemiologic and economic burden worldwide, and the most frequent form is cholesterol gallstone disease. RECENT FINDINGS: Major pathogenetic factors for cholesterol gallstones include a genetic background, hepatic hypersecretion of cholesterol, and supersaturated bile which give life to precipitating cholesterol crystals that accumulate and grow in a sluggish gallbladder. Additional factors include mucin and inflammatory changes in the gallbladder, slow intestinal motility, increased intestinal absorption of cholesterol, and altered gut microbiota. Mechanisms of disease are linked with insulin resistance, obesity, the metabolic syndrome, and type 2 diabetes. The role of nuclear receptors, signaling pathways, gut microbiota, and epigenome are being actively investigated. SUMMARY: Ongoing research on cholesterol gallstone disease is intensively investigating several pathogenic mechanisms, associated metabolic disorders, new therapeutic approaches, and novel strategies for primary prevention, including lifestyles.

Implications of gallbladder cholesterolosis and cholesterol polyps?

BACKGROUND: The clinical significance of cholesterolosis has not been well established but there are some provocative, if not robust, studies of the role it may play in the pathophysiology of pancreatitis and biliary dyskinesia, as well as hypercholesterolemia. Our aim was to take advantage of a very large cholecystectomy (CCY) database to support or refute these potentially important reported associations. MATERIALS AND METHODS: A retrospective review of 6868 patients who underwent CCY from 2001-2013 was performed. Comparisons were made using the student t-test for continuous and chi-square analysis for categorical, variables. RESULTS: Among patients for whom the CCY was the primary operation, 1053 (18%) had cholesterolosis and 4596 did not. Compared to those without cholesterolosis, those with cholesterolosis were no more likely to have elevated cholesterol levels (P = 0.64) nor low gallbladder ejection fraction (P = 0.2). To evaluate cholesterolosis as a cause of pancreatitis, all patients with gallstones were eliminated, leaving 639 patients. Among these, not only was cholesterolosis not associated with more pancreatitis, but rather there was not a single patient with or without cholesterolosis who had pancreatitis. CONCLUSIONS: Despite prior reports of associations between cholesterolosis and elevated serum cholesterol, depressed ejection fraction, and increased risk of pancreatitis, careful analysis of this current, larger data set does not support these associations. Any patient with stones or sludge, or with biliary dyskinesia, and appropriate symptoms, should be considered for CCY, with or without suspected cholesterolosis.

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.

Gallbladder dysfunction: how much longer will it be controversial?

BACKGROUND: Motility disorders of the biliary tree [biliary dyskinesia, including both gallbladder dysfunction (GBD), and sphincter of Oddi dysfunction] are difficult to diagnose and to treat. SUMMARY: There is controversy in the literature in particular regarding the criteria that should be used to select patients for cholecystectomy (CCY) in cases of suspected GBD. The current review covers the history, diagnosis, and treatment of GBD. Key Messages: Only >85% of patients with suspected GBD have relief following CCY, a much lower rate than the nearly 100% success rate following CCY for gallstone disease. Unfortunately, the literature is lacking, and there are no universally agreed-upon criteria for selecting which patients to refer for operation, although cholecystokinin (CCK)-enhanced hepatobiliary iminodiacetic acid scan is often used, with emphasis on an abnormally low gallbladder ejection fraction or pain reproduction at CCK administration. There is a clear need for large, well-designed, more definitive, prospective studies to better identify the indications for and efficacy of CCY in cases of GBD.

Symptomatic cholelithiasis and functional disorders of the biliary tract.

Symptomatic cholelithiasis and functional disorders of the biliary tract present with similar signs and symptoms. The functional disorders of the biliary tract include functional gallbladder disorder, dyskinesia, and the sphincter of Oddi disorders. Although the diagnosis and treatment of symptomatic cholelithiasis are relatively straightforward, the diagnosis and treatment of functional disorders can be much more challenging. Many aspects of the diagnosis and treatment of functional disorders are in need of further study. This article discusses uncomplicated gallstone disease and the functional disorders of the biliary tract to emphasize and update the essential components of diagnosis and management.

Cholecystectomy in Danish children--a nationwide study.

BACKGROUND: An increase in the frequency of cholecystectomy in children has been described during the last decades. Part of the reason is that more cholecystectomies in children are performed for dyskinesia of the gallbladder and not only for gallstone disease. We conducted the first nationwide study to describe outcome of cholecystectomies performed in children in Denmark by using data from the national Danish Cholecystectomy Database (DCD). METHODS: In the DCD, two data sources were combined: administrative data from the National Patient Registry (NPR) and clinical data entered into the secure Web site by the surgeon immediately after the operation. In the present analysis, we have included children ≤ 15 years from the five year period January 1, 2006, to December 31, 2010. RESULTS: In the study period 35,444 patients were operated with a cholecystectomy. Of these, 196 (0.5%) were ≤ 15 years. The median age was 14 years, and 82% were girls. Predisposing medical factors for gallstones (despite obesity) were found in only 5%. More than 50% were overweight, and one third were obese. Ninety-seven percent of the operations were completed laparoscopically, and the conversion rate was 0. 5%. Nearly half of the operations (45%) were performed as same day surgery, and 80% of the children stayed in hospital 0-1 day without readmission. 91% were discharged within 3 days and not readmitted. Morbidity was low, and no bile duct lesions occurred. The 30 day mortality was zero. CONCLUSION: Our nationwide outcome results indicate good quality with 91% of the patients discharged within 3 days without readmission, no bile duct injuries, and no mortality. All patients except two were operated for symptomatic gallstone disease in accordance to the Danish national guidelines. We have not experienced a demand or a need to expand the indications for cholecystectomy beyond gallstone disease.

Concomitant cholecystectomy during laparoscopic Roux-en-Y gastric bypass in obese patients is not justified: a meta-analysis.

While LRYGB has become a cornerstone in the surgical treatment of morbidly obese patients, concomitant cholecystectomy during LRYGB remains a matter of debate. The aim of this meta-analysis was to estimate the rate and morbidity of subsequent cholecystectomy after laparoscopic Roux-en-Y gastric bypass (LRYGB) in obese patients. A meta-analysis was performed analyzing the rate and morbidity of subsequent cholecystectomy in patients who underwent LRYGB without concomitant cholecystectomy. Thirteen studies met the inclusion criteria. The rate of subsequent cholecystectomy was 6.8 % (95 % CI, 5.0-8.7 %) based on 6,048 obese patients who underwent LRYGB without concomitant cholecystectomy. The rate of subsequent cholecystectomy due to biliary colic or gallbladder dyskinesia was 5.3 %; due to cholecystitis, 1.0 %; choledocholithiasis, 0.2 %; and biliary pancreatitis, 0.2 %. The mortality after subsequent cholecystectomy was 0 % (95 % CI, 0-0.1 %). The surgery-related complication rate after subsequent cholecystectomy was 1.8 % (95 % CI, 0.7-3.4 %) resulting in a risk of 0.1 % (95 % CI, 0.03-0.3 %) to suffer from a cholecystectomy-related complication in patients undergoing LRYGB without concomitant cholecystectomy. A prophylactic concomitant cholecystectomy during LRYGB should be avoided in patients without cholelithiasis and exclusively be performed in patients with symptomatic biliary disease.

[Biliary dysfunctions and their prevention].

THE AIM OF REVIEW: To present the up-to-date methods of prophylaxis of biliary system pathology. ORIGINAL POSITION: The number of patients with biliary tract pathology is constantly growing up. Participation of psychovegetative state in the development of gallbladder dysfunction was confirmed. CONCLUSION: Revealing and treatment of gallbladder dysfunction, treatment of disorders of psychovegetative disorders system in patients with dysfunction of gallbladder is the necessity for successful prophylaxis of chronic cholecystitis, cholelithiasis, pancreatitis.

Gallbladder dyskinesia: fact or fiction?

Gallbladder dyskinesia is a functional (motility) disorder of the gallbladder resulting in episodic abdominal pain that, in carefully selected cases, resolves with cholecystectomy. It is a diagnosis of exclusion: several functional and organic disorders have to be excluded, and confounding factors addressed, before a diagnosis of gallbladder dyskinesia can be entertained. The combination of high clinical suspicion and an abnormally low gallbladder ejection fraction on cholecystokinin stimulated-cholescintigraphy predict benefit from removing the gallbladder.

[Pathogenetic basis of pharmaceutical hepatitis induced by depakine in children].

42 children with epilepsy receved treatment by depakin drug. We defined the factors of lipid exchange processes of liver and their correlation between itself and with changes in immune status. The results of the studies indicated shaping the medical hepatitis with cholestatic syndrome on background of the long acceptance of depakin. Metabolic desadaptation was conditioned by glicolis activation in the condition of the oxygen deficit in tissue.

Biliary dyskinesia.

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.

Biliary dyskinesia in the pediatric patient.

The term biliary dyskinesia commonly describes a motility disorder of the biliary tract that is divided into two main categories: gallbladder dyskinesia (GBD) and sphincter of Oddi dysfunction (SOD). SOD is further subdivided into biliary SOD and pancreatic SOD. GBD causes typical biliary colic without gallstones, whereas SOD typically presents with recurrent pancreatitis or chronic abdominal pain, usually after cholecystectomy. GBD and SOD are uncommon in children. Based on adult experience, this review discusses the diagnosis and treatment of GBD and SOD in the pediatric population.

Prolonged urinary incontinence and biliary dyskinesia following abdominal contact with jellyfish tentacles.

A 16-year-old girl was seriously stung on her abdomen by a jellyfish as she jumped on her small surfboard. She and her mother identified the animal from photographs as Chrysaora fuscescens. Within several minutes the girl developed a massive abdominal cutaneous eruption composed of hundreds of punctuate erythematous papules and macules, which persisted for 5 to 7 days. Persistent urinary incontinence and biliary dyskinesia appeared over the following night. It is theorized that a systemic uptake of venom occurred percutaneously after contact of the jellyfish tentacles with her abdominal skin. The result was an injury to the urinary and biliary bladders. This is the first case report of such sequellae after topical contact with a marine animal. The causal relationship of these abnormalities with the sting is suggested by their temporal association. The gallbladder disorder required surgical intervention, but spontaneous resolution of the urinary bladder dysfunction occurred within 20 months.

[Some features of functional gastroenterological diseases in young people].

Gastroenterological diseases are the most widespread ones in the structure of the diseases among adults and young patients. Functional gastroenterological diseases present a particular issue as with them chronical gastroenterological and bile-excreting diseases may start. The author analyzed current state of this issue, epidemiology of gastroesophageal reflux disease, gastric dyspepsia and biliary dyskinesia in young patients (15-30 years). Peculiarities of this pathology have been underlined. It attracts attention of clinicians to this problem; let diagnostics of functional gastroenterological diseases be improved.

Biliary dyskinesia in pediatrics.

Biliary dyskinesia is a potential cause for acalculous biliary colic in pediatric patients. A triad of symptoms and signs, consisting of abdominal pain (with or without associated nausea or fatty food intolerance), absence of gallstones, and an abnormally low cholecystokinin-stimulated gallbladder ejection fraction is used to diagnose the disorder. In several small pediatric case series, cholecystectomy resulted in symptomatic improvement in a majority of patients with biliary dyskinesia. However, the diagnosis of biliary dyskinesia and appropriate management remain controversial. This review discusses the purported pathophysiology of biliary dyskinesia and the data available regarding diagnosis and treatment of this entity in the pediatric population.