Gallbladder dysfunction

Gallbladder dysfunction, or functional gallbladder disorder, refers to biliary pain due to motility disturbance of the gallbladder without gallstones, biliary sludge, microlithiasis or microcrystals. The disorder has previous been known by several other names, including gallbladder dyskinesia, gallbladder dysmotility, and cystic duct syndrome.

Epidemiology

An estimated 8% of men and 21% of women who report biliary pain have normal gallbladder ultrasound scans, and 20-25% of cholecystectomies performed in recent years have been for gallbladder dysfunction .

Clinical presentation

Patients commonly present with recurrent episodic biliary pain, typically described as right upper quadrant or epigastric pain that can radiate to the back or right shoulder. The pain can be associated with nausea, vomiting and sweating. Episodes typically last for between 30 minutes to six hours. An association with meals, particularly fatty meals, is common but not always a feature . There are usually normal results for common laboratory investigations for workup of biliary pain, including bilirubin, ALT, ALP, GGT, and lipase.

Pathology

The underlying etiology of the disturbance to gallbladder motility is incompletely understood. Associations with obesity, other gastrointestinal tract motility disorders, and abnormalities of bile composition have been suggested .

Radiographic features

Ultrasound

Ultrasound is typically performed as the modality of choice for investigation of biliary pain. In gallbladder dysfunction, ultrasound examination of the gallbladder is usually normal, with no cholelithiasis, biliary sludge, thickened gallbladder wall or hyperemia.

Cholescintigraphy

Cholescintigraphy (HIDA) examination can assess the gallbladder ejection fraction by filling the gallbladder with radiotracer, then measuring the radioactivity as the gallbladder empties through the cystic duct. An ejection fraction of <33% (may be 35 to 40% depending on different protocols at different institutions) after 60 min is indicative of impaired gallbladder emptying and gallbladder dysfunction.

Treatment and prognosis

Cholecystectomy is the mainstay of treatment for gallbladder dysfunction, with patients generally considered suitable for surgery if they have a fitting clinical presentation, no appropriate alternative diagnosis and a low gallbladder ejection fraction on cholescintigraphy.

Differential diagnosis

• cholelithiasis
• biliary sludge
• gallbladder microcalculi
• cholesterol polyps

Practical points

• diagnosis of exclusion in patients with biliary pain; firstly exclude other causes
• cholescintigraphy can confirm the diagnosis, with a low ejection fraction