Biliary dyskinesia is an enigmatic but important condition to consider in the evaluation of patients with right upper quadrant pain. A thorough history, work-up and examination are needed, as this diagnosis is primarily a diagnosis of exclusion. Proper selection of patients for cholecystectomy is essential in order to avoid unnecessary operative intervention. Show What is biliary dyskinesia?Biliary dyskinesia is a symptomatic functional disorder of the gallbladder whose precise etiology is unknown. It may be due to metabolic disorders that affect the motility of the GI tract, including the gallbladder, or to a primary alteration in the motility of the gallbladder itself. Biliary dyskinesia presents with a symptom complex that is similar to those with biliary colic. What are the symptoms?Biliary dyskinesia presents with a symptom complex that is similar to those with biliary colic.
How is it diagnosed?In order to diagnose biliary dyskinesia, the patient should have right upper quadrant pains similar to biliary colic but have a normal ultrasound examination of the gallbladder (no stones, sludge, microlithiasis, gallbladder wall thickening or CBD dilation). For patients who are suspected to have biliary dyskinesia, the Rome III diagnostic criteria for functional gallbladder disorders should be considered. These include:
When and how should a HIDA scan be obtained?If a patient meets these criteria and has a normal ultrasound examination, a HIDA scan should be considered. Recently updated criteria for the performance of hepatobiliary scintigraphy should be followed to determine the gallbladder ejection fraction. These guidelines recommend imaging and CCK infusion at a slow and constant rate (0.02 micrograms/kg) over 60 minutes. Also included are important clinical considerations prior to testing.
Who should have a cholecystectomy?Patients who have episodes of biliary type right upper quadrant pain, without structural abnormalities by ultrasound and an abnormal HIDA scan should be considered for cholecystectomy. An abnormal ejection fraction is considered to be less than 38% when the test is administered according to the guidelines described above. Some authors and experts recommend that the symptom complex should also be of sufficient duration (i.e. at least three months) before considering cholecystectomy. Common pitfalls in the diagnosis of biliary dyskinesiaPerformance of a HIDA scan in the absence of the symptom complex outlined above (Rome III criteria)
Failure to adequately exclude other structural diseases that could explain the symptoms
Performance of a HIDA scan while the patient is acutely ill or on medications that inhibit gallbladder function
Failure to obtain complete laboratory studies (liver enzymes, conjugated bilirubin, amylase/lipase)
Treatment OptionsCholecystectomy is the only known effective treatment for the diagnosis of biliary dyskinesia. A period of observation can and should be offered however if the symptom complex has been of short duration or there remains concern that other etiologies may be the primary contributor to the patient’s symptoms. A trial of medical therapy and/or dietary manipulation should be considered for those thought to have functional bowel motility issues. How effective is cholecystectomy for biliary dyskinesia?Although initial studies in the early 1990s suggested that 80-90% of patients have symptom resolution with cholecystectomy, this has not held up in clinical practice. The likelihood of symptom relief at one year after cholecystectomy is variable and highly dependent on patient selection but ranges from 50-70%. For More InformationFor more information about the surgical treatment of biliary dyskinesia at UW Health, visit our liver and pancreas program. Get the latest clinical updates from the University of Wisconsin Department of SurgerySign up for our newsletter to get the latest clinical information, free online CME, and more. Learn more about the University of Wisconsin Department of SurgeryWe provide world class patient care, move surgery forward with innovative research, and train the next generation of surgeons. Does HIDA scan shows ejection fraction?Your doctor might use a HIDA scan as part of a test to measure the rate at which bile is released from your gallbladder (gallbladder ejection fraction).
What is considered a high ejection fraction for gallbladder?Biliary dyskinesia, or hypokinesia of the gallbladder, is accepted as an ejection fraction less than 35%, while an accepted normal functioning gallbladder ejection fraction is greater than 35%.
What does low EF on HIDA scan mean?With a normal abdominal ultrasound (US), a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. Biliary dyskinesia or low gallbladder EF (EF < 35%) is a recognized indication for cholecystectomy.
What does it mean if your gallbladder ejection fraction is low?They'll also measure your gallbladder “ejection fraction,” which is how much bile your gallbladder ejects when it contracts. If your ejection fraction is less than 40%, and if no medications or hormone therapies can explain your reduced gallbladder motility, they'll diagnose gallbladder biliary dyskinesia.
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