Testing for atypical gallbladder disease

A patient shows up at a doctor’s office because of abdominal pain; this cramping pain starts from the middle abdomen and extends to the right side below rib cage. Occasionally, this is accompanied by mid-chest pain and nausea, especially after devouring a thick, juicy, medium well, two-inch thick ribeye. After surfing the Internet and talking to friends and relatives, the patient is convinced that his gallbladder is the culprit and now he tells his doctor that he is ready to have it removed.

However, there is a hitch; the gallbladder ultrasound – that time-honored diagnostic test to detect gallbladder anomalies – is normal! Since there is a host of abdominal disorders that can mimic gallbladder disease, the experienced physician resists the temptation of recommending immediate surgery without further diagnostic testing, lest surgery just becomes a dangerously futile exercise.

There are anecdotal reports describing patients with signs and symptoms suggestive of gallbladder disease who are “cured” after removal of the gallbladder, notwithstanding their normal ultrasounds. Yet, others presenting with classic “textbook symptoms” of gallbladder disorders are not benefited by surgery. Hence, is there a specific test to determine whether cholecystectomy (removal of the gallbladder) would be beneficial in certain atypical gallbladder disorders?

Advances in nuclear medicine and the discovery of new radioactive tracers led to the emergence of a modern test of gallbladder function called CCK-HIDA (the acronym for, cholecystokinin-cholescintigraphy, hepatobiliary iminodiacetic acid) scan. This test stimulates gallbladder contraction and then calculates gallbladder ejection fraction (GBEF), akin to the test for cardiac or heart function. The HIDA scan “provides a physiologic, non-invasive and accurate quantitative assessment of gallbladder contraction.”

The premise is that if the gallbladder is not contracting normally, it induces pain or other biliary symptoms as if it were full of stones or other abnormalities. This condition of biliary pain in an otherwise anatomically normal gallbladder (normal ultrasound) but with abnormal HIDA scan is termed biliary dyskinesia. In this scenario, removing the gallbladder might benefit the patient.

For a few decades now, the HIDA scan has been used more frequently to determine whether cholecystectomy would benefit a subset of population suffering from “gallbladder symptoms” but have anatomically normal gallbladder tests. Unfortunately, some issues are still unresolved and remain controversial; for instance, the long-term results of gallbladder surgery based on the diagnosis of “biliary dyskinesia” need objective evaluation.

It appears that researchers analyzing this subject have concerns that need to be addressed before promoting HIDA as a standard. Some of the concerns “include lack of standardization of the test methodology, such as the dose of CCK, duration of administration, and what constitutes normal versus abnormal values.” The question of “whether or not abnormal test results are truly predictive of success with surgical intervention” is another major issue. Prospective and randomized trials are needed to answer these significant queries.

Presently, the consensus is that not all patients complaining of abdominal pain should undergo HIDA scan. This test is helpful in patients who fit the so-called Rome III criteria, namely:

The patient’s pain must be located in the epigastrium and right upper quadrant accompanied by: Episodes lasing 30 minutes or longer; recurrent symptoms occurring at different intervals; pain builds up to a steady level; must be severe enough to interrupt the patient’s daily activities or lead to an emergency room visit; pain is not relieved by bowel movements; pain is not relieved by postural change; pain is not relieved by antacids; do not have diseases that would explain the symptoms.

Reference : The Utilization of Cholecystokinin Cholescintigraphy in Clinical Practice. By Brain K Richmond, MD; John DiBaise, MD Harvey Ziesmman, MD. Journal of the American College of Surgeons. Volume 217. No.2 August 2013.

Dr. Cabasares is a board certified general surgeon and Fellow of the American College of Surgeons; he practices in Perry.

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