Functional Gallbladder Disorder – Introduction
- Biliary pain caused by gallbladder dysmotility in the absence of gallstones, sludge, or microlithiasis.
- It is a diagnosis of exclusion with no evidence of structural disease seen with normal hepatobiliary and pancreatic laboratory and diagnostic imaging modalities.
Synonyms
- Biliary dyskinesia
- Gallbladder dyskinesia
- Gallbladder spasm
- Acalculous biliary disease
- Chronic acalculous cholecystitis
- Chronic acalculous
- Gallbladder dysfunction
- Cystic duct syndrome
| ICD-10CM CODE | |
| K82.9 | Disease of gallbladder, unspecified |
EPIDEMIOLOGY & DEMOGRAPHICS
Incidence
Biliary dyspepsia has an incidence rate of 1% to 6%.
Prevalence
10% to 45% of total population report dyspepsia.
Predominant Sex & Age
There is a 3:1 female:male predominance.
Risk Factors
There is no consistent relationship to meals or fatty meal intake.
PHYSICAL FINDINGS & CLINICAL PRESENTATION
These patients present with typical biliary pain that fulfills the Rome III criteria:
- •Patients present with sporadic epigastric or right upper quadrant pain lasting for 30 min but less than 6 h.
- •Episodes are recurrent and occur in sporadic intervals (but not daily).
- •The pain is not relieved by bowel movements.
- •The pain is not relieved by postural movements.
- •The pain is not relieved by antacids.
- •The pain builds up to a steady level.
- •The pain is severe enough it impedes daily activities and may even require an emergency department visit.
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
- •Primary gallbladder disorders: Gallstones, cholecystitis
- •Pancreatobiliary disorders: Cholelithiasis, choledocholithiasis, pancreatitis, pancreatic neoplasm
- •Gastrointestinal disorders: Gastroesophageal reflux disorder, peptic ulcer disease, inflammatory bowel disease, irritable bowel syndrome, gastric or esophageal neoplasm
- •Metabolic disorders: Obesity, diabetes mellitus
- •Cholecystokinin deficiency: Celiac disease
WORKUP
- This is a diagnosis of exclusion in a patient with biliary pain. Patients will have normal blood test results and hepatobiliary and pancreatic enzymes, including aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), bilirubin, amylase, and lipase. Imaging, including abdominal ultrasound, is essentially normal without evidence of gallstone or gallbladder sludge pathology.
LABORATORY TESTS
Laboratory tests, including serum AST, ALT, ALP, bilirubin, gamma-glutamyl transferase, amylase, and lipase, are within normal limits.
IMAGING STUDIES
- •To exclude gallstone pathology, a transabdominal ultrasound is initial choice for imaging. Transabdominal ultrasound is capable of detecting gallstones up to 3 to 5 mm in size. Patients should fast for at least 8 h before ultrasound to optimize visualization of the gallbladder.
- •If gallstones or gallbladder are not found on ultrasound but still suspected, endoscopic ultrasound (EUS) may be used to detect microlithiasis or gallstones smaller than 3 mm.
- •Assessing gallbladder emptying through cholecystokinin (CCK)–stimulated cholescintigraphy is essential in the diagnosis. CCK-stimulated cholescintigraphy allows for the calculation of gallbladder ejection fraction (GBEF). Normal GBEF is >38%. Patients with a GBEF <35% to 40% with reproducible pain on CCK stimulation is suggestive of functional gallbladder disorder.
TREATMENT
In patients with appropriate evaluation for suspected functional gallbladder disorder, surgical management with cholecystectomy is the preferred method of treatment.
NONPHARMACOLOGIC THERAPY
Surgical cholecystectomy is the preferred method of treatment. Studies have shown symptomatic relief in up to 98% of patients postcholecystectomy.
ACUTE GENERAL Treatment
- •Initial management should include adequate analgesic control for abdominal pain.
- •Opioid analgesics should be avoided because they may exacerbate symptoms involved in a hypofunctioning gallbladder.
DISPOSITION
Patients with functional gallbladder disorder are often misdiagnosed. These patients require appropriate evaluation to exclude other hepatobiliary etiology. After they are properly diagnosed, these patients have a favorable prognosis after surgical intervention.
COMPLEMENTARY & ALTERNATIVE MEDICINE
Turmeric (Curcuma) has been known to alleviate biliary dyspepsia by stimulating gallbladder contractions.
REFERRAL
- •Gastroenterology consultation may be considered to rule out microlithiasis via EUS.
- •Surgical consultation should be considered for possible cholecystectomy in select patients.
PEARLS & CONSIDERATIONS
Functional gallbladder disorder is a diagnosis of exclusion. It is essential that other hepatobiliary pathology be ruled out first. CCK-stimulation scintigraphy showing a reduced GBEF without any other pathology is suggestive of this disorder. Patients fare well with surgical intervention.
