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{{Biliary dyskinesia}}
{{Biliary dyskinesia}}
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==Overview==
 
'''Biliary dyskinesia''' is a failure of proper movement of the [[sphincter of Oddi]].<ref name="pmid17761125">{{cite journal|author=George J, Baillie J |title=Biliary and gallbladder dyskinesia |journal=Curr Treat Options Gastroenterol |volume=10 |issue=4|pages=322–7 |year=2007 |month=August |pmid=17761125 |doi= |url=http://www.treatment-options.com/1092-8472/10/322}}</ref>
== Overview ==
[[Biliary Dyskinesia]] develops when there is a [[bile]] stasis in the absence of any mechanical obstruction. There is a dynamical obstruction rather than fixed mechanical obstruction. In this condition, bile can not be properly propelled from the [[gall bladder]] or can not properly flow out of the end of [[common bile duct]]. The [[motility]] disorders of functional [[gallbladder]] disorder (FGD) and [[sphincter of Oddi]] disorder (SOD), cause biliary colic in the absence of [[Gallstone disease|gallstones]]. The pain is usually crampy and in the [[Right upper quadrant|right upper quadrant (RUQ)]] about 30 minutes after a meal. Other [[Symptom|symptoms]] include intolerance to fatty food, [[bloating]], [[nausea and vomiting]]. The Rome IV [[Diagnosis|diagnostic]] criteria should be considered in patients with biliary pain and suspected [[motility]] disorders (functional [[gallbladder]] disorder and functional biliary [[sphincter of Oddi]] disorder). [[HIDA scan|HIDA scan]] with an abnormal [[gallbladder]] ejection fraction (<40%) is a supportive criteria for diagnosing biliary dyskinesia but is not required for the [[diagnosis]] anymore. [[sphincter of Oddi|Sphincter of Oddi]] manometry may be used to rule out functional biliary [[sphincter of Oddi]] disorder (SOD) in patients who have had a [[cholecystectomy]]. [[Laparoscopic]] [[cholecystectomy]] is used to treat biliary dyskinesia and endoscopic biliary [[sphincterotomy]] is performed in patients with [[sphincter of Oddi]] disorder (SOD) diagnosed by manometry.
 
== Pathophysiology ==
The exact [[pathophysiology]] of biliary dyskinesia is unknown.<ref name="pmid30846030">{{cite journal| author=Clark CJ| title=An Update on Biliary Dyskinesia. | journal=Surg Clin North Am | year= 2019 | volume= 99 | issue= 2 | pages= 203-214 | pmid=30846030 | doi=10.1016/j.suc.2018.11.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30846030  }} </ref> However, there have been some suggestions as the causes of biliary dyskinesia such as the following: the biliary pain in [[gallbladder]] dyskinesia may be the result of [[gallbladder]] [[inflammation]] due ineffective [[gallbladder]] contraction caused by [[gallbladder]] dysmotility,  visceral hypersensitivity, and [[Receptor (biochemistry)|receptor]] or [[Neurology|neurologic]] abnormalities.<ref name="pmid21222059">{{cite journal| author=Francis G, Baillie J| title=Gallbladder dyskinesia: fact or fiction? | journal=Curr Gastroenterol Rep | year= 2011 | volume= 13 | issue= 2 | pages= 188-92 | pmid=21222059 | doi=10.1007/s11894-010-0172-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21222059  }} </ref> Consequently, abnormality in [[gallbladder]] or [[sphincter of Oddi]] contraction results in [[inflammation]] and biliary pain.<ref name="pmid30846030">{{cite journal| author=Clark CJ| title=An Update on Biliary Dyskinesia. | journal=Surg Clin North Am | year= 2019 | volume= 99 | issue= 2 | pages= 203-214 | pmid=30846030 | doi=10.1016/j.suc.2018.11.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30846030  }} </ref>
 
== Causes ==
The following [[motility]] disorders cause biliary colic without the presence of [[Gallstone disease|gallstones]]: functional [[gallbladder]] disorder (FGD) and biliary [[sphincter of Oddi]] disorder (SOD).<ref name="pmid12974505">{{cite journal| author=Shaffer E| title=Acalculous biliary pain: new concepts for an old entity. | journal=Dig Liver Dis | year= 2003 | volume= 35 Suppl 3 | issue=  | pages= S20-5 | pmid=12974505 | doi=10.1016/s1590-8658(03)00089-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12974505  }} </ref>
 
== Differentiating Biliary dyskinesia from other Diseases ==
Biliary dyskinesia should be differentiated from other disorders that caused [[Right upper quadrant|right upper quadrant (RUQ)]] pain, such as [[Abdomen|abdominal]] disorders with pain similar to biliary pain, [[Peptic ulcer|peptic ulcer disease (PUD)]], [[Gastroesophageal reflux disease|gastroesophageal reflux disease (GERD)]], [[Irritable bowel syndrome|irritable bowel syndrome (IBS)]], coronary artery disease, costochondritis, and [[Musculoskeletal disorders|musculoskeletal disorder]]. <ref name="pmid30846030">{{cite journal| author=Clark CJ| title=An Update on Biliary Dyskinesia. | journal=Surg Clin North Am | year= 2019 | volume= 99 | issue= 2 | pages= 203-214 | pmid=30846030 | doi=10.1016/j.suc.2018.11.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30846030  }} </ref>
 
== Epidemiology and Demographics ==
The [[incidence]] of [[cholecystectomy]] procedure for biliary dyskinesia has been reported to be 85 cases per million individuals in the United States and about 25 cases per million individuals outside the United States.<ref name="pmid25771131">{{cite journal| author=Preston JF, Diggs BS, Dolan JP, Gilbert EW, Schein M, Hunter JG| title=Biliary dyskinesia: a surgical disease rarely found outside the United States. | journal=Am J Surg | year= 2015 | volume= 209 | issue= 5 | pages= 799-803; discussion 803 | pmid=25771131 | doi=10.1016/j.amjsurg.2015.01.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25771131  }} </ref> The prevalence of functional [[gallbladder]] disorder (FGD) and [[sphincter of Oddi]] disorder (SOD) is unknown.<ref name="pmid29132521">{{cite journal| author=Wilkins T, Agabin E, Varghese J, Talukder A| title=Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia. | journal=Prim Care | year= 2017 | volume= 44 | issue= 4 | pages= 575-597 | pmid=29132521 | doi=10.1016/j.pop.2017.07.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29132521  }} </ref>
 
== Natural History and Prognosis ==
[[Symptom|Symptoms]] of biliary dyskinesia have been reported to resolve without any [[Invasive (medical)|invasive]] procedure in about half of the patients.<ref name="pmid25193389">{{cite journal| author=Bielefeldt K, Saligram S, Zickmund SL, Dudekula A, Olyaee M, Yadav D| title=Cholecystectomy for biliary dyskinesia: how did we get there? | journal=Dig Dis Sci | year= 2014 | volume= 59 | issue= 12 | pages= 2850-63 | pmid=25193389 | doi=10.1007/s10620-014-3342-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25193389  }} </ref> Patients with [[gallbladder]] dyskinesia (GD) that have typical classic biliary symptoms are more likely to have improvement after [[cholecystectomy]] compared to those with atypical symptoms.<ref name="pmid19542850">{{cite journal| author=Carr JA, Walls J, Bryan LJ, Snider DL| title=The treatment of gallbladder dyskinesia based upon symptoms: results of a 2-year, prospective, nonrandomized, concurrent cohort study. | journal=Surg Laparosc Endosc Percutan Tech | year= 2009 | volume= 19 | issue= 3 | pages= 222-6 | pmid=19542850 | doi=10.1097/SLE.0b013e3181a74690 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19542850  }} </ref> Relief of [[Symptom|symptoms]] has been reported in 80% of the patients that were diagnosed with [[sphincter of Oddi]] disorder (SOD) by manometry and treated with [[sphincterotomy]].<ref name="pmid12095476">{{cite journal| author=Toouli J| title=Biliary Dyskinesia. | journal=Curr Treat Options Gastroenterol | year= 2002 | volume= 5 | issue= 4 | pages= 285-291 | pmid=12095476 | doi=10.1007/s11938-002-0051-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12095476  }} </ref> 
 
== Diagnosis ==
 
=== Diagnostic Criteria ===
The Rome IV [[Diagnosis|diagnostic]] criteria should be considered in patients with biliary pain and suspected [[motility]] disorders (functional [[gallbladder]] disorder and functional biliary [[sphincter of Oddi]] disorder).<ref name="pmid27144629">{{cite journal| author=Cotton PB, Elta GH, Carter CR, Pasricha PJ, Corazziari ES| title=Rome IV. Gallbladder and Sphincter of Oddi Disorders. | journal=Gastroenterology | year= 2016 | volume=  | issue=  | pages=  | pmid=27144629 | doi=10.1053/j.gastro.2016.02.033 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27144629  }} </ref>
 
=== History and Symptoms ===
In order to exclude other disorders, the patient's history is important in the [[diagnosis]] of biliary dyskinesia. [[Symptom|Symptoms]] of biliary dyskinesia are characterized by biliary colic symptoms and include: [[postprandial]] pain in the [[RUQ|right upper quadrant (RUQ)]] (that radiate to the [[Flanks|flank]], [[Human back|back]], and right [[scapula]]), intolerance to fatty food, pain in the evening or awaking the patient at night, [[bloating]], [[nausea and vomiting]].<ref name="pmid30846030">{{cite journal| author=Clark CJ| title=An Update on Biliary Dyskinesia. | journal=Surg Clin North Am | year= 2019 | volume= 99 | issue= 2 | pages= 203-214 | pmid=30846030 | doi=10.1016/j.suc.2018.11.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30846030  }} </ref>
 
=== Physical Examination ===
[[Symptom|Symptoms]] of biliary dyskinesia are characterized by biliary colic symptoms. The following clinical presentations are not likely due to functional [[Bile duct|biliary]] disorder: positive Murphy’s sign, constant [[abdominal pain]] without [[tenderness]], [[jaundice]], and intermittent [[abdominal pain]] and [[Cramp|cramps]] with episodes of [[diarrhea]] or [[constipation]]. <ref name="pmid30846030">{{cite journal| author=Clark CJ| title=An Update on Biliary Dyskinesia. | journal=Surg Clin North Am | year= 2019 | volume= 99 | issue= 2 | pages= 203-214 | pmid=30846030 | doi=10.1016/j.suc.2018.11.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30846030  }} </ref>
 
===Laboratory Findings===
The initial laboratory work-up should include: [[liver function tests]] ([[Aspartate aminotransferase|AST]], [[Alanine transaminase|ALT]], and total [[bilirubin]]), [[amylase]], and [[lipase]].<ref name="pmid30846030">{{cite journal| author=Clark CJ| title=An Update on Biliary Dyskinesia. | journal=Surg Clin North Am | year= 2019 | volume= 99 | issue= 2 | pages= 203-214 | pmid=30846030 | doi=10.1016/j.suc.2018.11.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30846030  }} </ref>
 
=== CT ===
[[Computed tomography|CT scan]] is not helpful in diagnosing [[gallbladder]] or biliary diseases.<ref name="pmid30846030">{{cite journal| author=Clark CJ| title=An Update on Biliary Dyskinesia. | journal=Surg Clin North Am | year= 2019 | volume= 99 | issue= 2 | pages= 203-214 | pmid=30846030 | doi=10.1016/j.suc.2018.11.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30846030  }} </ref>
 
=== Ultrasound ===
[[Ultrasound]] is required in these patients in order to exclude structural conditions such as [[gallstone disease]] or [[cancer]].<ref name="pmid29132521">{{cite journal| author=Wilkins T, Agabin E, Varghese J, Talukder A| title=Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia. | journal=Prim Care | year= 2017 | volume= 44 | issue= 4 | pages= 575-597 | pmid=29132521 | doi=10.1016/j.pop.2017.07.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29132521  }} </ref> [[Ultrasound]] may be used in order to diagnose [[Sphincter of Oddi|sphincter of oddi]] disorders (SOD) by measuring the [[Common bile duct|common bile duct (CBD)]] diameter.<ref name="pmid16842450">{{cite journal| author=Sgouros SN, Pereira SP| title=Systematic review: sphincter of Oddi dysfunction--non-invasive diagnostic methods and long-term outcome after endoscopic sphincterotomy. | journal=Aliment Pharmacol Ther | year= 2006 | volume= 24 | issue= 2 | pages= 237-46 | pmid=16842450 | doi=10.1111/j.1365-2036.2006.02971.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16842450  }} </ref>
 
=== Other Imaging Findings===
[[HIDA scan|Hepatobiliary iminodiacetic acid (HIDA)]] with an abnormal [[gallbladder]] ejection fraction (<40%) is a supportive criteria for diagnosing biliary dyskinesia but is not required for the [[diagnosis]] anymore.<ref name="pmid30846030">{{cite journal| author=Clark CJ| title=An Update on Biliary Dyskinesia. | journal=Surg Clin North Am | year= 2019 | volume= 99 | issue= 2 | pages= 203-214 | pmid=30846030 | doi=10.1016/j.suc.2018.11.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30846030  }} </ref><ref name="pmid27144629">{{cite journal| author=Cotton PB, Elta GH, Carter CR, Pasricha PJ, Corazziari ES| title=Rome IV. Gallbladder and Sphincter of Oddi Disorders. | journal=Gastroenterology | year= 2016 | volume=  | issue=  | pages=  | pmid=27144629 | doi=10.1053/j.gastro.2016.02.033 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27144629  }} </ref> [[Non-invasive (medical)|Noninvasive]] procedures that may be used to evaluate and diagnose  [[sphincter of Oddi]] disorders (SOD) are: [[ultrasound]], [[HIDA scan]], and [[Magnetic resonance cholangiopancreatography|MRCP]].<ref name="pmid16842450">{{cite journal| author=Sgouros SN, Pereira SP| title=Systematic review: sphincter of Oddi dysfunction--non-invasive diagnostic methods and long-term outcome after endoscopic sphincterotomy. | journal=Aliment Pharmacol Ther | year= 2006 | volume= 24 | issue= 2 | pages= 237-46 | pmid=16842450 | doi=10.1111/j.1365-2036.2006.02971.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16842450  }} </ref>
 
=== Other Diagnostic Studies ===
[[Endoscopic retrograde cholangiopancreatography|ERCP]] and [[sphincter of Oddi]] manometry may be used to rule out functional biliary [[sphincter of Oddi]] disorder (SOD) in patients who have had a cholecystectomy.<ref name="pmid30846030">{{cite journal| author=Clark CJ| title=An Update on Biliary Dyskinesia. | journal=Surg Clin North Am | year= 2019 | volume= 99 | issue= 2 | pages= 203-214 | pmid=30846030 | doi=10.1016/j.suc.2018.11.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30846030  }} </ref>  Although [[sphincter of Oddi]]  manometry is the diagnostic tool for evaluating  [[sphincter of Oddi]] disorders (SOD), it is an [[Invasive (medical)|invasive]] procedure and has risk for [[Complication (medicine)|complications]].<ref name="pmid29132521">{{cite journal| author=Wilkins T, Agabin E, Varghese J, Talukder A| title=Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia. | journal=Prim Care | year= 2017 | volume= 44 | issue= 4 | pages= 575-597 | pmid=29132521 | doi=10.1016/j.pop.2017.07.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29132521  }} </ref>
 
== Treatment ==
 
=== Medical Therapy ===
Medical therapy mostly includes of [[symptomatic treatment]] of [[abdominal pain]] and [[Intravenous therapy|IV]] [[Opiate|opiates]] are the drug of choice, although some studies have suggested that [[Opiate|opiates]] cause [[sphincter of Oddi]]  contraction.<ref name="pmid29132521">{{cite journal| author=Wilkins T, Agabin E, Varghese J, Talukder A| title=Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia. | journal=Prim Care | year= 2017 | volume= 44 | issue= 4 | pages= 575-597 | pmid=29132521 | doi=10.1016/j.pop.2017.07.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29132521  }} </ref><ref name="pmid16678563">{{cite journal| author=Behar J, Corazziari E, Guelrud M, Hogan W, Sherman S, Toouli J| title=Functional gallbladder and sphincter of oddi disorders. | journal=Gastroenterology | year= 2006 | volume= 130 | issue= 5 | pages= 1498-509 | pmid=16678563 | doi=10.1053/j.gastro.2005.11.063 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16678563  }} </ref>
 
=== Surgery ===
[[Laparoscopic]] [[cholecystectomy]] is used to treat biliary dyskinesia. Endoscopic biliary [[sphincterotomy]] is performed in patients with [[sphincter of Oddi]] disorder (SOD) diagnosed by manometry.<ref name="pmid29132521">{{cite journal| author=Wilkins T, Agabin E, Varghese J, Talukder A| title=Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia. | journal=Prim Care | year= 2017 | volume= 44 | issue= 4 | pages= 575-597 | pmid=29132521 | doi=10.1016/j.pop.2017.07.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29132521  }} </ref>
 
=== Cost-Effectiveness of Therapy ===
There is insufficient evidence about the cost-effectiveness of therapy in biliary dyskinesia.
 
=== Future or Investigational Therapies ===
Further studies are required to assess the outcome of [[Surgery|surgical]] ([[cholecystectomy]]) versus nonsurgical [[Treatment|treatments]] (those used in treatment of other functional disorders) in bilary dyskinesia.<ref name="pmid32266192">{{cite journal| author=Simon DA, Friesen CA, Schurman JV, Colombo JM| title=Biliary Dyskinesia in Children and Adolescents: A Mini Review. | journal=Front Pediatr | year= 2020 | volume= 8 | issue=  | pages= 122 | pmid=32266192 | doi=10.3389/fped.2020.00122 | pmc=7105807 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32266192  }} </ref>


Failure of the biliary sphincter can be distinguished from the pancreatic sphincter.<ref name="pmid12095476">{{cite journal|author=Toouli J |title=Biliary Dyskinesia |journal=Curr Treat Options Gastroenterol |volume=5 |issue=4 |pages=285–291 |year=2002|month=August |pmid=12095476 |doi= |url=http://www.treatment-options.com/1092-8472/5/285}}</ref>
==References==
==References==


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Latest revision as of 00:53, 28 October 2020

Biliary dyskinesia Microchapters

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Overview

Pathophysiology

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Epidemiology and Demographics

Natural History, Complications and Prognosis

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Physical Examination

Laboratory Findings

CT

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Other Imaging Findings

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shakiba Hassanzadeh, MD[2]

Overview

Biliary Dyskinesia develops when there is a bile stasis in the absence of any mechanical obstruction. There is a dynamical obstruction rather than fixed mechanical obstruction. In this condition, bile can not be properly propelled from the gall bladder or can not properly flow out of the end of common bile duct. The motility disorders of functional gallbladder disorder (FGD) and sphincter of Oddi disorder (SOD), cause biliary colic in the absence of gallstones. The pain is usually crampy and in the right upper quadrant (RUQ) about 30 minutes after a meal. Other symptoms include intolerance to fatty food, bloating, nausea and vomiting. The Rome IV diagnostic criteria should be considered in patients with biliary pain and suspected motility disorders (functional gallbladder disorder and functional biliary sphincter of Oddi disorder). HIDA scan with an abnormal gallbladder ejection fraction (<40%) is a supportive criteria for diagnosing biliary dyskinesia but is not required for the diagnosis anymore. Sphincter of Oddi manometry may be used to rule out functional biliary sphincter of Oddi disorder (SOD) in patients who have had a cholecystectomy. Laparoscopic cholecystectomy is used to treat biliary dyskinesia and endoscopic biliary sphincterotomy is performed in patients with sphincter of Oddi disorder (SOD) diagnosed by manometry.

Pathophysiology

The exact pathophysiology of biliary dyskinesia is unknown.[1] However, there have been some suggestions as the causes of biliary dyskinesia such as the following: the biliary pain in gallbladder dyskinesia may be the result of gallbladder inflammation due ineffective gallbladder contraction caused by gallbladder dysmotility, visceral hypersensitivity, and receptor or neurologic abnormalities.[2] Consequently, abnormality in gallbladder or sphincter of Oddi contraction results in inflammation and biliary pain.[1]

Causes

The following motility disorders cause biliary colic without the presence of gallstones: functional gallbladder disorder (FGD) and biliary sphincter of Oddi disorder (SOD).[3]

Differentiating Biliary dyskinesia from other Diseases

Biliary dyskinesia should be differentiated from other disorders that caused right upper quadrant (RUQ) pain, such as abdominal disorders with pain similar to biliary pain, peptic ulcer disease (PUD), gastroesophageal reflux disease (GERD), irritable bowel syndrome (IBS), coronary artery disease, costochondritis, and musculoskeletal disorder. [1]

Epidemiology and Demographics

The incidence of cholecystectomy procedure for biliary dyskinesia has been reported to be 85 cases per million individuals in the United States and about 25 cases per million individuals outside the United States.[4] The prevalence of functional gallbladder disorder (FGD) and sphincter of Oddi disorder (SOD) is unknown.[5]

Natural History and Prognosis

Symptoms of biliary dyskinesia have been reported to resolve without any invasive procedure in about half of the patients.[6] Patients with gallbladder dyskinesia (GD) that have typical classic biliary symptoms are more likely to have improvement after cholecystectomy compared to those with atypical symptoms.[7] Relief of symptoms has been reported in 80% of the patients that were diagnosed with sphincter of Oddi disorder (SOD) by manometry and treated with sphincterotomy.[8] 

Diagnosis

Diagnostic Criteria

The Rome IV diagnostic criteria should be considered in patients with biliary pain and suspected motility disorders (functional gallbladder disorder and functional biliary sphincter of Oddi disorder).[9]

History and Symptoms

In order to exclude other disorders, the patient's history is important in the diagnosis of biliary dyskinesia. Symptoms of biliary dyskinesia are characterized by biliary colic symptoms and include: postprandial pain in the right upper quadrant (RUQ) (that radiate to the flank, back, and right scapula), intolerance to fatty food, pain in the evening or awaking the patient at night, bloating, nausea and vomiting.[1]

Physical Examination

Symptoms of biliary dyskinesia are characterized by biliary colic symptoms. The following clinical presentations are not likely due to functional biliary disorder: positive Murphy’s sign, constant abdominal pain without tenderness, jaundice, and intermittent abdominal pain and cramps with episodes of diarrhea or constipation. [1]

Laboratory Findings

The initial laboratory work-up should include: liver function tests (AST, ALT, and total bilirubin), amylase, and lipase.[1]

CT

CT scan is not helpful in diagnosing gallbladder or biliary diseases.[1]

Ultrasound

Ultrasound is required in these patients in order to exclude structural conditions such as gallstone disease or cancer.[5] Ultrasound may be used in order to diagnose sphincter of oddi disorders (SOD) by measuring the common bile duct (CBD) diameter.[10]

Other Imaging Findings

Hepatobiliary iminodiacetic acid (HIDA) with an abnormal gallbladder ejection fraction (<40%) is a supportive criteria for diagnosing biliary dyskinesia but is not required for the diagnosis anymore.[1][9] Noninvasive procedures that may be used to evaluate and diagnose sphincter of Oddi disorders (SOD) are: ultrasound, HIDA scan, and MRCP.[10]

Other Diagnostic Studies

ERCP and sphincter of Oddi manometry may be used to rule out functional biliary sphincter of Oddi disorder (SOD) in patients who have had a cholecystectomy.[1] Although sphincter of Oddi manometry is the diagnostic tool for evaluating sphincter of Oddi disorders (SOD), it is an invasive procedure and has risk for complications.[5]

Treatment

Medical Therapy

Medical therapy mostly includes of symptomatic treatment of abdominal pain and IV opiates are the drug of choice, although some studies have suggested that opiates cause sphincter of Oddi contraction.[5][11]

Surgery

Laparoscopic cholecystectomy is used to treat biliary dyskinesia. Endoscopic biliary sphincterotomy is performed in patients with sphincter of Oddi disorder (SOD) diagnosed by manometry.[5]

Cost-Effectiveness of Therapy

There is insufficient evidence about the cost-effectiveness of therapy in biliary dyskinesia.

Future or Investigational Therapies

Further studies are required to assess the outcome of surgical (cholecystectomy) versus nonsurgical treatments (those used in treatment of other functional disorders) in bilary dyskinesia.[12]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Clark CJ (2019). "An Update on Biliary Dyskinesia". Surg Clin North Am. 99 (2): 203–214. doi:10.1016/j.suc.2018.11.004. PMID 30846030.
  2. ↑ Francis G, Baillie J (2011). "Gallbladder dyskinesia: fact or fiction?". Curr Gastroenterol Rep. 13 (2): 188–92. doi:10.1007/s11894-010-0172-6. PMID 21222059.
  3. ↑ Shaffer E (2003). "Acalculous biliary pain: new concepts for an old entity". Dig Liver Dis. 35 Suppl 3: S20–5. doi:10.1016/s1590-8658(03)00089-6. PMID 12974505.
  4. ↑ Preston JF, Diggs BS, Dolan JP, Gilbert EW, Schein M, Hunter JG (2015). "Biliary dyskinesia: a surgical disease rarely found outside the United States". Am J Surg. 209 (5): 799–803, discussion 803. doi:10.1016/j.amjsurg.2015.01.003. PMID 25771131.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Wilkins T, Agabin E, Varghese J, Talukder A (2017). "Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia". Prim Care. 44 (4): 575–597. doi:10.1016/j.pop.2017.07.002. PMID 29132521.
  6. ↑ Bielefeldt K, Saligram S, Zickmund SL, Dudekula A, Olyaee M, Yadav D (2014). "Cholecystectomy for biliary dyskinesia: how did we get there?". Dig Dis Sci. 59 (12): 2850–63. doi:10.1007/s10620-014-3342-9. PMID 25193389.
  7. ↑ Carr JA, Walls J, Bryan LJ, Snider DL (2009). "The treatment of gallbladder dyskinesia based upon symptoms: results of a 2-year, prospective, nonrandomized, concurrent cohort study". Surg Laparosc Endosc Percutan Tech. 19 (3): 222–6. doi:10.1097/SLE.0b013e3181a74690. PMID 19542850.
  8. ↑ Toouli J (2002). "Biliary Dyskinesia". Curr Treat Options Gastroenterol. 5 (4): 285–291. doi:10.1007/s11938-002-0051-9. PMID 12095476.
  9. ↑ 9.0 9.1 Cotton PB, Elta GH, Carter CR, Pasricha PJ, Corazziari ES (2016). "Rome IV. Gallbladder and Sphincter of Oddi Disorders". Gastroenterology. doi:10.1053/j.gastro.2016.02.033. PMID 27144629.
  10. ↑ 10.0 10.1 Sgouros SN, Pereira SP (2006). "Systematic review: sphincter of Oddi dysfunction--non-invasive diagnostic methods and long-term outcome after endoscopic sphincterotomy". Aliment Pharmacol Ther. 24 (2): 237–46. doi:10.1111/j.1365-2036.2006.02971.x. PMID 16842450.
  11. ↑ Behar J, Corazziari E, Guelrud M, Hogan W, Sherman S, Toouli J (2006). "Functional gallbladder and sphincter of oddi disorders". Gastroenterology. 130 (5): 1498–509. doi:10.1053/j.gastro.2005.11.063. PMID 16678563.
  12. ↑ Simon DA, Friesen CA, Schurman JV, Colombo JM (2020). "Biliary Dyskinesia in Children and Adolescents: A Mini Review". Front Pediatr. 8: 122. doi:10.3389/fped.2020.00122. PMC 7105807 Check |pmc= value (help). PMID 32266192 Check |pmid= value (help).

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