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Speed Your Diagnosis of This Gallbladder Disorder

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Speed Your Diagnosis of This Gallbladder Disorder David Ivan Croteau, MD, FAAFP Lakeland Regional Speed your diagnosis Medical Center, Lakeland, Fla of this gallbladder disorder david.croteau@lrmc. com Fatty infiltration of the internal organs—and the The author reported no potential conflict of interest inflammation associated with it—is an increasingly relevant to this article. common cause of gallbladder dysfunction. Here’s what to keep in mind to identify it without delay. CASE c Dionne J, a 38-year-old woman with a Bmi of 32, pres- Practice ents with a 2-month history of right upper abdominal pain. The recommendatIonS pain is intermittent and often begins after eating, she reports, › Use the Rome III guidelines particularly when a meal includes fatty foods. She has no nau- to diagnose and treat func- sea, vomiting, diarrhea, constipation, or fever, and the pain is tional gallbladder disorder; not getting progressively worse. when this benchmark is fol- When the pain comes on, ms. J says, it lasts about an hour, lowed, cholecystectomy results Pain after sometimes less. it is colicky in nature, and not relieved with gallbladder in ~90% resolution rate. B surgery? Consider bowel movements or position change. The patient tried raniti- › Keep in mind that classic sphincter of oddi dine 150 mg twice a day for 2 weeks, with no relief. you suspect dysfunction biliary symptoms, particu- functional gallbladder disorder. But is ms. J a candidate for a larly right upper quadrant cholecystectomy? What would you do next? David ivan croteau, mD, pain, pain after eating, and FAAFP reproduction of pain with cholecystokinin injection, are ver the past 2 decades, the incidence of cholecystec- www.jfponline.com highly predictive of a success- tomies due to functional gallbladder disorder (FGBD) 1 ful postoperative outcome. C O has multiplied, going from about 5% to 20% to 25%. But definitive information about the etiology of FGBD has not › Offer cholecystectomy to pa- tients who present with classic kept pace. biliary symptoms and an ab- Although the Rome III diagnostic guidelines for FGBD, 2 normal hepatobiliary imino- published in 2006, remain the standard of care, a number diacetic acid (HIDA) scan. C of more recent studies have added to our understanding of this disorder. This review of the diagnosis and treatment of Strength of recommendation (SOR) FGBD incorporates both the Rome III guidelines and the A Good-quality patient-oriented evidence latest findings. The text and tables that follow can help you B Inconsistent or limited-quality recognize this clinical entity earlier, minimize the number of patient-oriented evidence tests needed to arrive at a definitive diagnosis, and establish C Consensus, usual practice, a plan of care that is consistent with both the guidelines and opinion, disease-oriented evidence, case series the evidence. As obesity rates rise, so does gallbladder dysfunction Obesity has been shown to produce a chronic proinflammato- ry state throughout the body,3-6 which has been linked to fatty 4 The Journal of family PracTice | JANUARY 2013 | Vol 62, no 1 tABLE Rome III diagnostic criteria for functional gallbladder disorder must include episodes of pain located in the epigastrium and/or right upper quadrant and all of the following findings: • Gallbladder is present • normal liver enzymes, conjugated bilirubin, and amylase/lipase • episodes lasting ≥30 minutes • recurrent symptoms occurring at different intervals (not daily) • The pain builds up to a steady level • The pain is moderate to severe enough to interrupt the patient’s daily activities or lead to an emergency department visit • The pain is not relieved by bowel movements • The pain is not relieved by postural change • The pain is not relieved by antacids • exclusion of other structural disease that would explain the symptoms Supportive criteria The pain may present with one or more of the following findings: Evidence suggests that • Pain is associated with nausea and vomiting gallstones • Pain radiates to the back and/or right infrasubscapular region develop as a • Pain awakens the patient from sleep in the middle of the night result of Source: Behar et al. Gastroenterology. 2006;130:1498-1509.2 used with permission from elsevier. progressively worsening inflammation infiltration of the gallbladder (among other moved from patients who had classic biliary and dysmotility. organs) and impaired contractility.3,6-9 symptoms but no gallstones.11 A study by Al-Azzawi et al highlighted FGBD appears to be initiated by fatty infil- the importance of increased fat in the gall- tration of the gallbladder wall, causing increasing bladder wall as a key cause of dysmotility.10 levels of inflammation and steatocholecystitis The researchers compared wall thickness, that lead to poor motility.3,4,6-10 This in turn alters inflammation, and the amount of fat in bile composition, which can lead to sludge and the walls of gallbladders that had been re- stone formation.2,6,10 The finding by Al-Azzawi moved for both acalculous and calculous et al of greater thickness and inflammation disease with the characteristics of gallblad- in the walls of gallbladders with calculi sug- ders removed for reasons unrelated to or- gests that gallstones result from progressively gan dysfunction (the controls). Those with worsening inflammation and dysmotility.10 dysmotility, they found, had more fat in the wall but the same wall thickness as the controls. The amount of fat in the walls was Steps to take similar for the acalculous and the calcu- for a definitive diagnosis lous groups, but the gallbladders in which A diagnosis of FGBD requires a history of clas- stones were found had more inflammation sic gallbladder symptoms, many but not all of and increased wall thickness.10 which are specified in the Rome III diagnos- Several other studies have found evi- tic criteria (tAblE). Classic symptoms include dence of both inflammation and fatty depos- nausea, vomiting, right upper quadrant pain, its in the walls of gallbladders removed for pain after eating, and reproduction of pain acalculous disease.2,4,11-13 with cholecystokinin (CCK) injection. Cramp- In one study, researchers found chronic ing, bloating, reflux, diarrhea, fullness, and inflammation in 99% of gallbladders re- epigastric pain are atypical symptoms.2,11 conTinueD JfPonline.com Vol 62, no 1 | JANUARY 2013 | The Journal of family PracTice 5 AlGORItHM Diagnostic workup and management of functional gallbladder disorder (Rome III) ima G e S cour T clinical history, lfTs/pancreatic enzyme, e S uS, eGD y of: nuclear me Structural alterations D icine D e me P ar D T ical cen normal findings men T , la T er, K elan l a K appropriate investigation D elan and treatment re G D ional , FLA right upper ccK cholescintigraphy quadrant pain, (hiDa scan), if available pain after meals, and pain reproduced with an injection of cholecystokinin GBef <40% GBef >40% are the most highly predictive of long-term cholecystectomy reassess symptom relief from ccK, cholecystokinin; eGD, esophagogastroduodenoscopy; GBef, gallbladder ejection fraction; hiDa, hepatobiliary iminodiacetic cholecystectomy. acid; lfTs, liver function tests; uS, ultrasound. Source: Behar J et al. Gastroenterology. 2006;130:1498-1509.2 used with permission from elsevier. rule out structural causes done—a hepatobiliary iminodiacetic acid There is no single test for FGBD, and a defini- (HIDA) scan is the next step in the diagnos- tive diagnosis can be made only after structural tic pathway. The scan tests the gallbladder’s causes of the symptoms (eg, gallstones, tumor, ejection fraction (EF), revealing the percent- sclerosis, and cirrhosis) have been ruled out age of radioactive dye ejected from the organ (AlGORItHM).2 Initial tests include liver and after CCK is injected (FIGUrE).2 The injection pancreatic enzyme laboratory screening and of CCK should be done over a minimum of 30 an ultrasound of the upper right quadrant. In minutes, the guidelines specify. The shorter patients with FGBD, both the lab tests and the the time frame used for the injection, the less ultrasound will be normal. likely that the pain will be reproduced or that The Rome III guidelines also call for an the EF findings will be reliable.14 esophagogastroduodenoscopy (EGD) to rule Most researchers define a normal EF out esophagitis, gastritis, and duodenitis, al- as >35%,10,11,13 but the Rome III criteria use a though some researchers have held that if cutoff of 40%. A patient who has an EF <40% the other tests are normal, this test need not and meets the other guideline criteria is diag- be done.12 If the EGD is also normal—or not nosed with FGBD. 6 The Journal of family PracTice | JANUARY 2013 | Vol 62, no 1 FunCtionAl GALLBlADDER Disorder FIGUrE Abnormal vs normal HIDA scans: What you’ll see ima A b G e S cour T e S y of: nuclear me D icine D e me P ar D T ical cen men T , la T er, K elan l a K D elan re G D ional , FLA The larger amount of contrast dye retained in the abnormal scan (a) compared with the normal scan (B) is evidence of a poor ejection fraction. CASE c on physical examination, ms. J has pain of symptoms with a cholecystectomy when in the right upper quadrant, with no guarding the Rome III criteria are followed for pa- or rebound, and normal bowel sounds. her tient selection has been found to be close to liver and pancreatic enzyme tests are normal, 90%.11,15-20 Two recent studies have examined and an ultrasound shows no sludge, no stones, the resolution rate for FGBD, with conflicting and mild edema of the gallbladder wall. The results.11,12 Both studies were based on long- patient declines an eGD because of the cost term postoperative follow-up, ranging from but undergoes a hiDa scan—which reveals 6 to 24 months.
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