Biliary Dyskinesia

Biliary dyskinesia (functional gallbladder disorder) is biliary type pain with gallbladder hypomotility in the absence of gallstones or structural disease.

• Rome IV definition: biliary pain with normal liver tests, lipase and no stones or sludge, with an abnormal gallbladder ejection fraction.
• Prevalence 8% of adults with biliary pain, more in women and young people; increasing diagnosis in children.
• Mechanism: impaired gallbladder contractile response to cholecystokinin, cystic duct dysfunction.
• Associated conditions: functional gastrointestinal disorders, opioid use, diabetes, obesity.
• Diagnosis of exclusion.

• Episodic epigastric or right upper quadrant pain of 30 minutes or more, steady, building to a plateau, occurring at different intervals, not relieved by bowel movements or antacids, may radiate to back or shoulder, wakes from sleep.
• Nausea, vomiting, postprandial fullness.
• Normal examination; positive Murphy sign is uncommon.
• Red flags: fever, jaundice, weight loss.

• Normal liver enzymes, bilirubin, amylase and lipase during pain.
• Ultrasound without stones, sludge, polyps, wall thickening.
• Upper endoscopy and CT to exclude peptic and pancreatic causes.
• Cholecystokinin cholescintigraphy (HIDA with sincalide 0.02 micrograms/kg infused over 60 minutes): ejection fraction below 35 to 38% at 30 to 60 minutes with reproduction of pain supports the diagnosis. Stop opioids for 24 hours and avoid fasting longer than 24 hours.
• Exclude sphincter of Oddi dysfunction, functional dyspepsia, irritable bowel syndrome, chronic pancreatitis.

• Lifestyle: low fat diet, treat constipation, stop opioids.
• Medical therapy has limited evidence: ursodeoxycholic acid 10 to 15 mg/kg, antispasmodics (hyoscine butylbromide 10 to 20 mg), peppermint oil, neuromodulators (amitriptyline 10 to 25 mg) for overlapping functional disorders.
• Cholecystectomy (laparoscopic) for patients with typical biliary pain, gallbladder ejection fraction below 35%, and exclusion of other causes: symptom resolution in 70 to 90%, with a lower rate (about 50%) in atypical pain.
• Perioperative cefazolin 2 g IV.
• Patients with normal ejection fraction or atypical symptoms should not have surgery.
• Postoperative persistence: evaluate for sphincter of Oddi dysfunction, bile acid diarrhoea and functional pain.
• Follow up in 3 months.