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Functional Gallbladder Disorder: An Increasingly Common Diagnosis


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Am Fam Physician. 2014 May 15;89(10):779-784.

  Related article: Surgical and Nonsurgical Management of Gallstones

Functional gallbladder disorder is a motility disorder of the gallbladder that results in decreased gallbladder contractility and colicky pain. The term is used to cover a constellation of symptoms that have led to their codification in the Rome III criteria (Table 1).1 Previously, functional gallbladder disorder was called chronic acalculous cholecystitis, acalculous cholecystitis, biliary dyskinesia, or biliary dysmotility. It is being diagnosed more often in the office setting, increasing the number of cholecystectomies performed for functional gallbladder disorder over the past two decades from a baseline incidence of 5% to between 20% and 25%.2 Functional gallbladder disorder should be a diagnostic consideration in any patient presenting with classic biliary symptoms and with normal findings on ultrasonography of the right upper quadrant and normal liver and pancreatic enzyme levels.3

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Table 1.

Diagnostic Criteria from the Rome III Guidelines for Functional Gallbladder Disorder

Must include episodes of pain located in the epigastrium and/or right upper quadrant and all of the following:

Gallbladder is present

Liver enzyme, conjugated bilirubin, and amylase/lipase levels are normal

Episodes last 30 minutes or longer

Recurrent symptoms occur 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

Other structural diseases that would explain the symptoms are excluded

Supportive criteria

The pain may be present with at least one of the following:

Pain is associated with nausea and vomiting

Pain radiates to the back and/or right infrasubscapular region

Pain awakens the patient from sleep in the middle of the night


Adapted from Behar J, Corazziari E, Guelrud M, Hogan W, Sherman S, Toouli J. Functional gallbladder and sphincter of oddi disorders. Gastroenterology. 2006;130(5):1500, with permission from Elsevier. http://www.sciencedirect.com/science/journal/00165085.

Table 1.

Diagnostic Criteria from the Rome III Guidelines for Functional Gallbladder Disorder

Must include episodes of pain located in the epigastrium and/or right upper quadrant and all of the following:

Gallbladder is present

Liver enzyme, conjugated bilirubin, and amylase/lipase levels are normal

Episodes last 30 minutes or longer

Recurrent symptoms occur 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

Other structural diseases that would explain the symptoms are excluded

Supportive criteria

The pain may be present with at least one of the following:

Pain is associated with nausea and vomiting

Pain radiates to the back and/or right infrasubscapular region

Pain awakens the patient from sleep in the middle of the night


Adapted from Behar J, Corazziari E, Guelrud M, Hogan W, Sherman S, Toouli J. Functional gallbladder and sphincter of oddi disorders. Gastroenterology. 2006;130(5):1500, with permission from Elsevier. http://www.sciencedirect.com/science/journal/00165085.

Etiologically, there seems to be an association between functional gallbladder disorder and obesity. Obesity has been shown in several studies to result in fatty infiltration of the internal organs and to produce a chronic proinflammatory state throughout the body.47 Fatty infiltration of the gallbladder and impaired gallbladder contractility secondary to inflammation have also been demonstrated in several studies.4,710 These result in poor motility, leading to altered bile composition. The formation of biliary sludge and stones seems to be an end product rather than a cause of biliary symptoms.

Including functional gallbladder disorder in the differential diagnosis of a patient with classic biliary symptoms who has a negative workup is essential. The Rome III criteria can be helpful for guiding the diagnosis and especially for avoiding misdiagnosis. A hepatobiliary iminodiacetic acid (HIDA) scan should be performed in patients meeting Rome III criteria in the presence of normal findings on ultrasonography of the right upper quadrant and normal levels of liver and pancreatic enzymes. A HIDA scan determines how well the gallbladder contracts by measuring the percentage of radioactive dye ejected from the gallbladder over a period of time. An ejection fraction less than 40% is abnormal.

Because not all patients with suspected functional gallbladder disorder will benefit from surgery, clinical considerations and the results of the HIDA scan should be taken into account before proceeding to surgical management. The presence of classic biliary symptoms is of prognostic importance. One study found that patients with classic biliary symptoms were 22 times more likely to have relief after a cholecystectomy than patients who present atypically (P < .0002).11

The Rome III criteria help maximize the chance that surgical outcomes will have long-term clinical benefit. When the criteria are met in the setting of abnormal findings on HIDA scan, cholecystectomy should strongly be considered. The resolution of symptoms after cholecystectomy is near 90% if the Rome III criteria are used for patient selection, with an emphasis on the presenting symptoms.913

Author disclosure: No relevant financial affiliations.

Address correspondence to David Ivan Croteau, MD, FAAFP, at david.croteau@lrmc.com. Reprints are not available from the author.

REFERENCES

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1. Behar J, Corazziari E, Guelrud M, Hogan W, Sherman S, Toouli J. Functional gallbladder and sphincter of oddi disorders. Gastroenterology. 2006;130(5):1498–1509....

2. Al-Azzawi HH, Nakeeb A, Saxena A, Maluccio MA, Pitt HA. Cholecystosteatosis: an explanation for increased cholecystectomy rates. J Gastrointest Surg. 2007;11(7):835–842.

3. Croteau DI. Speed your diagnosis of this gallbladder disorder. J Fam Pract. 2013;62(1):4–8.

4. Goldblatt MI, Swartz-Basile DA, Al-Azzawi HH, Tran KQ, Nakeeb A, Pitt HA. Nonalcoholic fatty gallbladder disease: the influence of diet in lean and obese mice. J Gastrointest Surg. 2006;10(2):193–201.

5. Tsai CJ. Steatocholecystitis and fatty gallbladder disease. Dig Dis Sci. 2009;54(9):1857–1863.

6. Bastard JP, Maachi M, Lagathu C, et al. Recent advances in the relationship between obesity, inflammation, and insulin resistance. Eur Cytokine Netw. 2006;17(1):4–12.

7. Pitt HA. Hepato-pancreato-biliary fat: the good, the bad and the ugly. HPB (Oxford). 2007;9(2):92–97.

8. Amaral J, Xiao ZL, Chen Q, Yu P, Biancani P, Behar J. Gallbladder muscle dysfunction in patients with chronic acalculous disease. Gastroenterology. 2001;120(2):506–511.

9. Portincasa P, Di Ciaula A, Baldassarre G, et al. Gallbladder motor function in gallstone patients: sonographic and in vitro studies on the role of gallstones, smooth muscle function, and gallbladder wall inflammation. J Hepatol. 1994;21(3):430–440.

10. Merg AR, Kalinowski SE, Hinkhouse MM, Mitros FA, Ephgrave KS, Cullen JJ. Mechanisms of impaired gallbladder contractile response in chronic acalculous cholecystitis. J Gastrointest Surg. 2002;6(3):432–437.

11. Carr JA, Walls J, Bryan LJ, Snider DL. The treatment of gallbladder dyskinesia based upon symptoms: results of a 2-year, prospective, non-randomized, concurrent, cohort study. Surg Laparosc Endosc Percutan Tech. 2009;19(3):222–226.

12. Singhal V, Szeto P, Norman H, Walsh N, Cagir B, VanderMeer TJ. Biliary dyskinesia: how effective is cholecystectomy? J Gastrointest Surg. 2012;16(1):135–141.

13. Francis G, Baillie J. Gallbladder dyskinesia: fact or fiction? Curr Gastroenterol Rep. 2011;13(2):188–192.



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