Enlarged gallbladder no stones

Gallbladder Disease

There are many different types of gallbladder disease.

Gallstones

Gallstones develop when substances in the bile (such as cholesterol, bile salts, and calcium) or substances from the blood (like bilirubin) form hard particles that block the passageways to the gallbladder and bile ducts.

Gallstones also tend to form when the gallbladder doesn’t empty completely or often enough. They can be as small as a grain of sand or as large as a golf ball.

Numerous factors contribute to your risk of gallstones. These include:

  • being overweight or obese
  • having diabetes
  • being age 60 or older
  • taking medications that contain estrogen
  • having a family history of gallstones
  • being female
  • having Crohn’s disease and other conditions that affect how nutrients are absorbed
  • having cirrhosis or other liver diseases

Cholecystitis is the most common type of gallbladder disease. It presents itself as either an acute or chronic inflammation of the gallbladder.

Acute cholecystitis

Acute cholecystitis is generally caused by gallstones. But it may also be the result of tumors or various other illnesses.

It may present with pain in the upper right side or upper middle part of the abdomen. The pain tends to occur right after a meal and ranges from sharp pangs to dull aches that can radiate to your right shoulder. Acute cholecystitis can also cause:

  • fever
  • nausea
  • vomiting
  • jaundice

Chronic cholecystitis

After several attacks of acute cholecystitis, the gallbladder can shrink and lose its ability to store and release bile. Abdominal pain, nausea, and vomiting may occur. Surgery is often the needed treatment for chronic cholecystitis.

Choledocholithiasis

Gallstones may become lodged in the neck of the gallbladder or in the bile ducts. When the gallbladder is plugged in this way, bile can’t exit. This may lead to the gallbladder becoming inflamed or distended.

The plugged bile ducts will further prevent bile from traveling from the liver to the intestines. Choledocholithiasis can cause:

  • extreme pain in the middle of your upper abdomen
  • fever
  • chills
  • nausea
  • vomiting
  • jaundice
  • pale- or clay-colored stools

Acalculous gallbladder disease

Acalculous gallbladder disease is inflammation of the gallbladder that occurs without the presence of gallstones. Having a significant chronic illness or serious medical condition has been shown to trigger an episode.

Symptoms are similar to acute cholecystitis with gallstones. Some risk factors for the condition include:

  • severe physical trauma
  • heart surgery
  • abdominal surgery
  • severe burns
  • autoimmune conditions like lupus
  • blood stream infections
  • receiving nutrition intravenously (IV)
  • significant bacterial or viral illnesses

Biliary dyskinesia

Biliary dyskinesia occurs when the gallbladder has a lower-than-normal function. This condition may be related to ongoing gallbladder inflammation.

Symptoms can include upper abdominal pain after eating, nausea, bloating, and indigestion. Eating a fatty meal may trigger symptoms. There are usually no gallstones in the gallbladder with biliary dyskinesia.

Your doctor may need to use a test called a HIDA scan to help diagnosis this condition. This test measures gallbladder function. If the gallbladder can only release 35 to 40 percent of its contents or less, then biliary dyskinesia is usually diagnosed.

Sclerosing cholangitis

Ongoing inflammation and damage to the bile duct system can lead to scarring. This condition is referred to as sclerosing cholangitis. However, it’s unknown what exactly causes this disease.

Nearly half the people with this condition don’t have symptoms. If symptoms do occur, they can include:

  • fever
  • jaundice
  • itching
  • upper abdominal discomfort.

Approximately 60 to 80 percent of people with this condition also have ulcerative colitis. Having this condition does increase the risk of liver cancer as well. Currently, the only known cure is a liver transplant.

Medications that suppress the immune system and those that help break down thickened bile can help manage symptoms.

Gallbladder cancer

Cancer of the gallbladder is a relatively rare disease. There are different types of gallbladder cancers. They can be difficult to treat because they’re not often diagnosed until late in the disease’s progression. Gallstones are a common risk factor for gallbladder cancer.

Gallbladder cancer can spread from the inner walls of the gallbladder to the outer layers and then on to the liver, lymph nodes, and other organs. The symptoms of gallbladder cancer may be similar to those of acute cholecystitis, but there may also be no symptoms at all.

Gallbladder polyps

Gallbladder polyps are lesions or growths that occur within the gallbladder. They’re usually benign and have no symptoms. However, it’s often recommended to have the gallbladder removed for polyps larger than 1 centimeter. They have a greater chance of being cancerous.

Gangrene of the gallbladder

Gangrene can occur when the gallbladder develops inadequate blood flow. This is one of the most serious complications of acute cholecystitis. Factors that increase the risk of this complication include:

  • being male and over 45 years old
  • having diabetes

The symptoms of gallbladder gangrene can include:

  • dull pain in the gallbladder region
  • fever
  • nausea or vomiting
  • disorientation
  • low blood pressure

Abscess of the gallbladder

Abscess of the gallbladder results when the gallbladder becomes inflamed with pus. Pus is the accumulation of white blood cells, dead tissue, and bacteria. Symptoms may include upper right-sided pain in the abdomen along with fever and shaking chills.

This condition can occur during acute cholecystitis when a gallstone blocks the gallbladder completely, allowing the gallbladder to fill with pus. It’s more common in people with diabetes and heart disease.

Table I.
Other diagnoses Selected differentiating factors
Pain related to bowel movements
Associated constipation, diarrhea, postprandial urgency or other symptoms
IBS Associated bloating
Changing/fleeting location of pain
Response to antispasmodics, neuromodulators
Other risk factors for visceral hypersensitivity, such as longstanding narcotics
Response to antacids, Hp eradication, stopping NSAID, or promotility medications
Nausea-predominant symptoms
Dyspepsia Associated reflux-type symptoms or radiation into chest
Post-prandial distress/bloating
Abnormal EGD
Pain positional
Little to no relationship to meals
Musculoskeletal and neuropathic pain Associated back pains
Physical exam rib tenderness, reproduction with spine percussion, or increase tenderness when muscles tensed
Risk factors for chronic pancreatitis
Centrally located pain, often radiating to the back
Chronic pancreatitis Structural (CT/MRI/EUS/ERCP) or functional (endocrine/exocrine) abnormality in the pancreas
+/- Response to pancreatic enzymes

What urgent or emergent measures should be initiated even before the diagnosis is established?

N/A

What is the appropriate initial diagnostic approach to identify the specific underlying disease?

Ruling out occult lithiasis – imaging
Noninvasive biliary imaging

The main alternate diagnosis here is missed gallbladder lithiasis, which will have identical history and physical exam findings. Therefore, the initial test of choice is a gallbladder/RUQ ultrasound. Since this test is somewhat operator-dependent, if normal on one ultrasound, repeating this test in a more experienced center can be helpful. In addition, moving and shaking the gallbladder can be used as part of that procedure. It is less likely that this, and other maneuvers, can be done when a patient is in acute pain; therefore, if the original ultrasound was done during a pain attack, repeating when the pain has settled can allow a more thorough exam.

Although MRCP (magnetic resonance cholangiopancreatography) is well studied for choledocholithiasis, it is not as well studied in gallbladder stones. It is probably inferior to ultrasound for small stones and sludge, except perhaps in those patients with anatomy that limits the sensitivity of conventional RUQ ultrasounds, such as obesity (subcutaneous fat increases the distance from the skin surface to the gallbladder, decreases the movability of the gallbladder, and the fat attenuates ultrasound waves).

Endoscopic ultrasound (EUS) can detect missed lithiasis in up to 80% of patients with biliary pain and a normal RUQ ultrasound in some studies, but the frequency is likely much lower in atypical pain or after high-quality careful RUQ ultrasound. (See Figure 1.)

Figure 1.

Occult lithiasis on EUS, with arrows indicating 1-2 mm nonshadowing echogenicities representing bits of sludge seen to be floating and mobile on real-time imaging.

CT is not a good test for cholelithiasis but can detect wall thickening or pericholecystic fluid or alternate diagnoses in selected cases.

Invasive sampling

Endoscopic retrograde cholangiopancreatography (ERCP) to sample cystic duct or gallbladder bile is too dangerous (post-ERCP pancreatitis) for its low yield, and bile analysis for crystals is not done well enough in most centers anyway. Sampling of bile duct bile is probably not helpful. A study looking at EUS with gallbladder FNA to sample gallbladder bile for crystals was ended early because of a high rate of bile leaks, and this should not be done.

Gallbladder motility testing

After cholelithiasis has been carefully ruled out, the next step is to assess for dysmotility. The classic test for this is a scintigraphy (HIDA or DISIDA) scan to assess gallbladder filling and emptying. Poor emptying (generally <35% ), stimulated by cholecystokinin (CCK), is a sign of a motility problem or a problem with the gallbladder wall that affects its distensibility and flexibility, such as inflammation.

An exaggerated ejection fraction, indicating a possibly hyperkinetic/hypercontractile gallbladder, may also indicate a disorder that may respond to cholecystectomy, but that is more controversial.

It is generally thought that these motility tests are only moderately sensitive and specific for this condition and to predict response to therapy.

History and physical exam

Most patients are women (90% in the only randomized trial), just as in SOD, for an unclear reason.

The pains are typically 15 minutes to a few hours in duration, and are often following meals, especially in the evening, similar to symptomatic cholelithiasis. (Central) epigastric and RUQ pain locations are equally likely due to referral of foregut visceral pain to the center of the epigastrium in many people. It is unlikely to cause nausea alone and is unlikely to cause chronic pain; both these presentations can be seen, but response to cholecystectomy may be lower. Weight loss is uncommon but nausea and anticipatory fear of pain can reduce intake and can lead to mild weight changes.

Physical exam can be normal, especially between attacks, but mild to moderate tenderness in the epigastrium and/or RUQ is common. Murphy’s sign is not present. Maneuvers to exclude musculoskeletal causes for pain are useful in selected patients, including palpation with and without tensing of the abdominal wall and percussion of thoracic spine, especially if there is a positional component to the pain (worse when lifting, prolonged standing, bending over, etc.). Laboratory testing, including liver enzymes, is generally normal, but ,because of the prevalence of fatty liver, mild enzyme elevations (unrelated) can be seen. Hepatomegaly should be ruled out.

Atypical pain and nonbiliary testing

For less typical biliary pain (e.g., more chronic pain, associated nausea/bloating, associated constipation, or reflux/chest-pain), a trial of antacid medication and/or antispasmodic and/or osmotic laxative might be reasonable. Nausea-predominant presentations may warrant a gastric emptying study. Patients with partial response to antacid medication may warrant esophageal pH testing prior to resorting to cholecystectomy.

Almost all patients being considered for cholecystectomy for this syndrome should have an upper endoscopy to rule out upper GI pathology. Prior to this, exclusion of NSAIDs (nonsteroidal anti-inflammatory drugs) and/or testing and treating for H. pylori can be tried, as this has a small benefit over placebo in non-ulcer dyspepsia.

With regard to patients with colonic or other IBS-type symptoms, the clinician should consider performing a colonoscopy, especially when the patient is over the age of 50 and especially if gallbladder function testing is normal.

What is the diagnostic approach if this initial evaluation fails to identify the cause?

The presence of sphincter of Oddi dysfunction (SOD) in a patient that still has his/her gallbladder is a very controversial area, as this is generally felt to be a postcholecystectomy pain syndrome. Although referral to a tertiary center to consider an ERCP with manometry can be made, often those centers would prefer not to do that study in patients with a gallbladder (GB) in situ.

Empiric cholecystectomy in patients with a normal functional test and normal structural testing is selectively performed. However, a tertiary opinion should be obtained, other causes should be ruled out, and other empiric therapies exhausted. Patients should understand that it is very possible that gallbladder surgery will not help their pain.

What is the effectiveness of treatment?

Treatment consists of laparoscopic cholecystectomy.

Treatment efficacy varies from study to study but is as low as 30% to 50% in patients with atypical pain, nausea, or dyspepsia; however, the efficacy can be much higher in highly selected patients with typical biliary pain. A small percentage (<0.5%) of patients can have complications such as a bile leak or other duct injury, among others, but mortality is rare. Conversion to open cholecystectomy occurs uncommonly and takes on the risks of that laparotomy – longer recovery time, wound infections, etc.

The efficacy of empiric cholecystectomy in patients with normal gallbladder testing, including ultrasound and HIDA, is not known but anecdotally may be helpful in selected patients.

The efficacy of nonsurgical therapies, such as antispasmodics or neuromodulating drugs, is really unknown and largely unstudied, but these are reasonable to try in selected patients, especially if IBS is the differential.

The efficacy of ERCP with manometry-directed sphincterotomy for possible SOD (generally considered a post-cholecystectomy syndrome) in patients who are not postcholecystectomy is unclear. Limited subgroup analyses, such as using SOD outcome data from Indiana University, have shown some benefit even in patients with gallbladder in situ. This needs further study.

What’s the evidence?

Levine, R, Fromm, H. “Acalculous abdominal pain in patients with abnormal cholescintigraphy: is cholecystectomy the answer”. Gastroenterology. vol. 102. 1992. pp. 742-3.

DiBaise, JK, Oleynikov, D. “Does gallbladder ejection fraction predict outcome after cholecystectomy for suspected chronic acalculous gallbladder dysfunction? A systematic review”. Am J Gastroenterol. vol. 98. 2003. pp. 2605-11.

Gurusamy, KS, Junnarkar, S, Farouk, M, Davidson, BR. “Cholecystectomy for suspected gallbladder dyskinesia”. Cochrane Database of Syst Rev. 2009.

Fullarton, GM, Bell, G. “Prospective audit of the introduction of laparoscopic cholecystectomy in the west of Scotland. West of Scotland Laparoscopic Cholecystectomy Audit Group”. Gut. vol. 35. 1994. pp. 1121-6.

Gall, CA, Chambers, KJ. “Cholecystectomy for gall bladder dyskinesia: Symptom resolution and satisfaction in a rural surgical practice”. ANZ J Surg. vol. 72. 2002. pp. 731-4.

Goncalves, RM, Harris, JA, Rivera, DE. “Biliary dyskinesia: natural history and surgical results”. Am Surg. vol. 64. 1998. pp. 493-8.

Eversman, D, Fogel, EL, Rusche, M. “Frequency of abnormal pancreatic and biliary sphincter manometry compared with clinical suspicion of sphincter of Oddi dysfunction”. Gastrointest Endosc. vol. 50. 1999. pp. 637-41.

Jacobson, BC, Waxman, I, Parmar, K. “Endoscopic ultrasound-guided gallbladder bile aspiration in idiopathic pancreatitis carries a significant risk of bile peritonitis”. Pancreatology. vol. 2. 2002. pp. 26-9.

Biliary pain, no gallstones—remove the gallbladder, anyway?

CASE 1 › A 28-year-old woman (G0P0) came to our office with recurrent episodes of postprandial epigastric and right upper quadrant pain. Upper and lower endoscopy, sonography, body imaging, and laboratory tests were normal. A biliary nuclear scan showed an ejection fraction (EF) of 95%; normal is >35%. We made a diagnosis of biliary dyskinesia (BD) and recommended a laparoscopic cholecystectomy. The patient underwent this procedure and her pain was relieved. She has been much improved for 2 years, although she has since been diagnosed with an autoimmune disorder.

CASE 2 › A 21-year-old woman with right upper quadrant, postprandial, colicky pain presented to the emergency department. The episode lasted approximately 30 minutes and was followed by residual soreness. This episode was one of several that had been increasing in frequency and intensity. A sonogram showed a normal gallbladder and common duct. All laboratory tests were normal. She improved and was discharged. Outpatient evaluation included body imaging and endoscopy, which were negative. A hepatobiliary (HIDA) scan revealed an EF of 90%, and the scan reproduced her symptoms.

We diagnosed BD in this patient. After reviewing the risks and benefits of cholecystectomy, the patient consented to the procedure. She has been asymptomatic for 2 years.

Family physicians often are the first to evaluate patients with recurrent biliary colic. Biliary colic without gallstones—also known as BD or acalculous cholecystitis—is a functional disorder of the gallbladder or bile duct. Approximately 8% of men and 21% of women with biliary pain do not have gallstones.1-5

BD has been successfully treated with cholecystectomy. Physicians typically have viewed cholecystectomy as being effective primarily for patients with biliary pain who have a low EF (<35%).2-4 However, recent studies and our experience with cholecystectomy in these 2 patients with high EFs suggest that EF is only one of several factors to consider when deciding whether cholecystectomy might be appropriate for a given patient.

Which patients are most likely
 to benefit from cholecystectomy?

BD is a diagnosis of exclusion, considered when other upper abdominal disorders are eliminated. To receive a diagnosis of BD, patients must meet the Rome III criteria (TABLE).2

Before the advent of oral cholecystography in the 1920s, biliary disease was a clinical diagnosis confirmed by examination of the excised gallbladder.6 In 2 large studies conducted before cholecystography was in common use, researchers noted improvement in 75% to 85% of BD patients after cholecystectomy.7,8 Several years later, with the benefit, of cholecystography, Mackey9 reported similar improvement rates among patients with BD who underwent cholecystectomy.

Cholecystography has largely been replaced with HIDA scanning, which provides an objective measure of EF. Although some studies have suggested low EFs may predict which patients will benefit from cholecystectomy, others have suggested this value doesn’t tell the whole story.2,4,10,11 In some studies, patients who had biliary symptoms and a low EF (<35%) were found to be most likely to experience relief after cholecystectomy.2,4 More recently, in a chart review, DuCoin et al10 found that of 19 BD patients with an EF >35% who underwent cholecystectomy, 17 had complete symptom resolution, one had partial resolution, and one was unchanged. Only one abstract of a study of cholecystectomy for BD patients with a high EF (>80%) has been published.11 Of 28 patients who received cholecystectomy, 22 were asymptomatic after cholecystectomy and 5 others improved.11

Other tests to consider. A cholecystokinin infusion without a scan has been used to reproduce biliary colic; some physicians consider this to be diagnostic of BD and sufficient for cholecystectomy.12 Others have advocated endoscopic injection of botulinum into the sphincter of Oddi to differentiate pain arising from the sphincter of Oddi from pain in the gallbladder.5,13 If symptoms are relieved by this injection, an endoscopic biliary sphincterotomy—cutting of the biliary sphincter—is done. Cholecystectomy is reserved for patients whose pain is not relieved by botulinum. In an initial report, 25 BD patients received botulinum injections into the sphincter of Oddi; of the 11 whose pain was relieved by this injection, 10 underwent endoscopic biliary sphincterotomy, and pain resolved for all of these patients.13

Why we chose cholecystectomy
 for our patients


Despite a plethora of tests available to visualize and assess gallbladder and bile duct function, clinical assessment of BD by experienced physicians may be sufficient to determine which BD patients will benefit from cholecystectomy. In the cases we report on here, each patient had a high EF, but both met Rome III criteria and were experiencing clinically significant pain. Also, for both patients, a cholecystokinin infusion administered to calculate EF reproduced their pain. This clinical picture led us to recommend laparoscopic cholecystectomy, which ultimately relieved their symptoms.

PMC

DISCUSSION

Since present real-time ultrasonography shows high-quality imaging, the absence of a gallbladder image in a fasting patient must be considered pathological. Hublitz et al.6) reported that ultrasonic visualization of the gallbladder can be achieved with relative ease and reliability, with a 98% success rate using B-scan echography. In our study, the gallbladder was nonvisualized in 78 (1.02%) of 7582 cases. Among the 78 cases, 35 cases had previously undergone a cholecystectomy.

In most cases, the apparently absent gallbladder is, in fact, a small, chronically infected, contracted gallbladder1–5). Leopold et al4). found six patients with gallbladder nonvisualization, all of whom proved to have gallstones (100% positive accuracy). Harbin et al1). reported that 22 of 25 cases (88% positive accuracy) were found to have diseased gallbladders. Anderson and Harned5) noted that 10 of 13 cases with gallbladder nonvisualization were found to have cholelithiasis (77% positive accuracy). In our study, if 5 of the 31 cases in whom the etiology of gallbladder nonvisualization were not confirmed are excluded, 22 of 26 cases (84.6% positive accuracy) were found to have diseased gallbladders (Table 7).

Ultrasonography and oral cholecystography have been compared by many authors. Detwiler and associates7) reviewed the records of all patients cholecystectomized in their hospital from January 1977 to December 1979, a total of 374 patients. Seventy-six of these had both abdominal ultrasound and oral cholecystography performed preoperatively. The oral cholecystography accurately diagnosed gallbladder disease in 71 of these 76 patients, with 93.4 per cent accuracy, false positive in one patient, and false negative in 4 patients. Ultrasonography correctly predicted gallbladder disease in 66 of the 75 patients, with 86.8% accuracy, false positive in one patient, and false negatives in 9 patients. These authors recommended that ultrasound scanning should be employed as the initial screening study for all gallbladder disease, and that oral cholecystography should then follow in patients in whom ultrasonography fails to identify gallbladder calculi. Vas and Salem8) also recommended cholecystosonography as the initial study in the investigation of gallbladder disease by making a comparative retrospective study of 140 patients. Ultrasound was found to be 95% accurate for gallbladder disease, with a 5% false negative rate. Oral cholecystography was 96% accurate.

Some investigators9,10) have recommended the use of single-dose oral cholecystography as the routine first examination when gallbladder disease is suspected. If the gallbladder is not satisfactorily visualized on first examination, ultrasonic cholecystography can be done immediately. In an emergency, or for patients who might be pregnant, ultrasonic cholecystography should be available as the initial examination. In our hospital we perform ultrasonography as the initial screening test for gallbladder disease.

Harbin et al.1) studied follow-up data on 25 patients whose gallbladders were nonvisualized by oral cholecystography and reported that of the 24 patients proven by surgery (22 patients) or autopsy (2 patients), the positive accuracy for 11 patients with both an abnormal cholecystogram and nonvisualization by cholecystography was 100%. In our study, of the 16 cases which underwent oral cholecystography, abnormalities were found in 15 cases such as stone in 5 cases, nonvisualization in 9 cases, and faint visualization in one case (Table 3). Of the 9 cases whose gallbladders were nonvisualized on oral cholecystography, stone were found in 4 cases, cancer in one case, a normal-appearing gallbladder by ERCP in one case, and for 3 cases no additional radiological evaluation was done. A case whose gallbladder was faintly visualized received no additional evaluation

In general, intravenous cholangiography is indicated in diseases of the extrahepatic duct, but it should be applied when oral examination is impractical, such as, in emergencies due to time limitations, in cases of gastrointestinal irritation, withholding of oral sustenance, or the presence of nasogastric tubes. There is some disagreement concerning the utilization of intravenous cholangiography when there has been failure of the gallbladder to opacify after a second-day cholecystogram. In a series of 5,000 cases, Majahed and associates11) showed such failure of opacification to represent gallbladder disease in all instances. On the other hand, Wise12) has claimed that 10% of patients with gallbladder nonvisualization on oral cholecystography may have a normal intravenous cholangiogram and possibly not suffer from gallbladder disease.

In our study, intravenous cholangiography was done in 4 cases, which were confirmed by surgery to be cases of gallstone with chronic cholecystitis in 2 cases, choledocholithiasis with chronic cholecystitis in one case, and cancer of the gallbladder in one case. Intravenous cholangiography showed that the gallbladder was nonvisualized in all 4 cases, and that the biliary duct was not visualized in 2 cases, was filled with air in one case, and was normal in one case. In two (cancer and cholelithiasis with chronic cholecystitis) of the 4 cases, a cholecystogram was performed before intravenous cholangiography showed a nonvisualized gallbladder, and two (cholelithiasis with chronic cholecystitis and choledocholithiasis with chronic cholecystitis) underwent ERCP after intravenous cholangiography showed choledocholithiasis with a contracted gallbladder, and cholelithiasis with air in the biliary duct. Therefore, intravenous cholangiography did not aid in the determination of the etiology of gallbladder nonvisualization in any of the 4 cases

Endoscopic retrograde cholangiography is valuable in gallbladder disease when jaundice is present, particularly when there is a question of a possible co-existing disease in the biliary duct. In our study, of the 15 cases which underwent ERCP, there were 7 cases of nonvisualized gallbladder, 4 cases of cholelithiasis, 2 cases of contracted gallbladder, and 2 cases of a normal appearing gallbladder. The associated findings of the biliary duct included stone in 6 cases, cancer in one case, and normal in 8 cases. In one case, the biliary duct was filled with air in addition to stones. Surgical findings in 6 of the 7 cases which showed gallbladder nonvisualization by ERCP, were cholelithiasis in 4 cases, cancer of the gallbladder in one case, and cancer of the bile duct at the level of the cystic duct with a normal sized gallbladder in one case. In the remaining case, the biliary duct was normal on ERCP. Thus ERCP helped to determine the etiology of gallbladder nonvisualization by ultrasonography in 14 (93.3%) of the 15 cases.

Nonvisualization of the cystic duct and gallbladder by ERCP represents cystic duct obstruction when adequate filling of the biliary tree is obtained13). However, unless the biliary tree is filled to the second or third order of branches, no comment can be made on nonvisualization of the gallbladder. Sixty-three cases, whose gallbladders and cystic ducts were nonvisualized by ERCP although the rest of the biliary system was well visualized, were analyzed by Rohrmann and coworkers14), and three groups of patients with abnormal conditions were noted: (1) those with obstructing lesions of the distal common bile duct, 35 patients, (2) those with primary lesions of the cystic duct or gallbladder, 19 patients, and (3) those with obstructing lesions about the common hepatic/cystic duct junction, 8 patients. In the second group, 19 patients had actual obstructing lesions of the cystic duct or gallbladder, such as calculi in 14 patients, empyema of gallbladder or chronic obliterative cholecystitis in 3 patients, and carcinoma of the gallbladder in 2 patients.

Harbin et al.1) reported that 22 of 25 cases in whom the gallbladder could not be identified by cholecystosonography despite adequate fasting had diseased gallbladders with obliteration of the lume (cholelithiasis with chronic cholecystitis in 20 cases and carcinoma in 2 cases). In our study, the 5 cases in which the etiology of gallbladder nonvisualization was not confirmed were excluded from the 31 cases, 22 of the 26 cases were found to have diseased gallbladders such as chronic cholecystitis in 15 cases (among these 15, cholelithiasis was present in 13 cases, choledocholithiasis in 2 cases), cholelithiasis in 4 cases which were nonsurgerized, and cancer in 3 cases (among these chronic cholecystitis was present in 2 cases and the lumen was obliterated in one case).

There are many causes of gallbladder nonvisualization as described in the introduction. Of the 19 cases confirmed at the time of surgery, the reasons for gallbladder nonvisualization by ultrasonography were contracted gallbladder due to chronic cholecystitis in 17 cases due to cholelithiasis (13 cases), choledocholithiasis (2 cases) and cancer (2 cases), obliteration of the lumen due to cancer of the gallbladder in one case, and technical error due to an unusal location of the gallbladder in one case proven as having cancer of the bile duct at the level of the cystic duct.

The mechanisms accounting for gallbladder nonvisualization in our 4 cases of diagnostic error seemed to be technical error due to an unusual location of the gallbladder in three cases and obscuration of the gallbladder by intestinal gas in one case. According to Doust and Mahlad15), the causes accounting for gallbladder nonvisualization, using bistable B-mode scanning were small volume gallbladders or those with unusual shapes or locations. Harbin et al.1) reported that the mechanism accounting for gallbladder non-visualization in 3 cases (12%) of diagnostic error is obscure, but that the possible causes are physiologic contraction of the gallbladder because the patients are not truly fasting and obscuration of the gallbladder by adjacent gas pockets in the colon or small bowel.

In conclusion, we feel that careful examination should be done to detect an gallbladder unusually located or one obscured by intertinal gas in order to decrease the diagnostic error rate when the gallbladder is not visualized by ultrasonography. Also, we recommend oral cholecystography or ERCP for an ultrasonographicaly nonvisualized gallbladder.

Gallbladder disease: What you need to know

Some common health issues that can affect the gallbladder are:

Share on PinterestAbdominal pain can be a symptom of gallbladder disease.

Gallstones are the most frequently occurring form of gallbladder disease. Cholesterol and solidified bile make up these small stones, which form in the gallbladder.

Around 20 million people in the United States between the ages of 20 and 74 years have gallstones. Of these, 14 million are women.

There are often no symptoms, but gallstones can become trapped in an opening or duct inside the gallbladder.

This can result in a sudden pain in the abdomen, specifically between the rib cage and the belly button, just below the right ribs. The pain may spread to the side or the shoulder blade.

Other symptoms include:

  • abdominal pain that lasts several hours
  • nausea, vomiting, and loss of appetite
  • a fever and chills
  • a yellow tinge to the skin and the whites of the eyes
  • dark-colored urine and pale stools
  • itchy skin
  • heavy sweating

A person may also feel contractions as the gallbladder tries to expel a gallstone.

Using the bathroom, vomiting, and passing gas do not improve the pain.

Eating foods that contain a lot of fat can trigger the discomfort — which doctors call biliary colic — but it can happen without a specific trigger.

A person who experiences this pain should see a doctor, as complications can result.

A more severe gallstone blockage inside a bile duct can cause swelling in the gallbladder. The name of this condition is cholecystitis.

If a person does not receive treatment, serious complications can arise.

Cholecystitis can be acute or chronic.

Acute cholecystitis

A person first experiences sudden, intense pain. The pain may last 6–12 hours or longer.

There may also be:

  • nausea and vomiting
  • a fever
  • slight yellowing of the skin
  • swelling in the abdomen

An episode of acute cholecystitis usually clears within a week. If it does not go away, it may be a sign of something more serious.

Cholecystitis often results from gallstones, but it can stem from other conditions.

If cholecystitis does not involve gallstones, it can appear:

  • after major surgery
  • after a critical illness
  • as a result of an infection or a weak immune system

People with this form of cholecystitis can become very ill. If the inflammation is severe, it can result in a rupture of the gallbladder.

Chronic cholecystitis

Chronic cholecystitis is the result of long-term inflammation in the gallbladder. This occurs when the gallbladder does not drain properly.

The underlying cause may involve:

  • gallstones blocking a duct
  • high concentrations of bile salt and calcium
  • the gallbladder being unable to empty properly
  • sickle cell anemia

Symptoms include repeated episodes of sudden inflammation and upper body pain. The pain will be less severe than that of acute cholecystitis, and a person usually will not have a fever.

Cholecystitis can cause a number of serious complications. These include:

Gallbladder infection: If cholecystitis results from a buildup of bile, the bile may become infected.

Death of gallbladder tissue: Without treatment, cholecystitis can cause gallbladder tissue to die, and gangrene can develop. Dead tissue can also cause the gallbladder to tear or burst.

Torn gallbladder: A tear in the gallbladder can result from swelling or infection.

Both forms of cholecystitis can have life-threatening consequences. It is important to seek medical aid if a person shows symptoms.

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.

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.

  • Episodes of right upper quadrant pain
  • Severe pain that limits activities of daily living
  • Nausea associated with episodes of pain
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:

  • Pain episodes that last longer than 30 minutes
  • Recurrent symptoms that occur at variable intervals
  • Pain that is severe enough to interrupt daily activity or lead to ER visits
  • Pain that builds up to a steady level
  • Pain that is not relieved by bowel movements, postural changes, or antacids
  • Exclusion of other structural diseases that could explain the symptoms
  • Other supportive criteria include: association of pain with nausea and vomiting, radiation of the pain to the infrascapular region, and pain that wakes the patient in the middle of the night.
  • Normal liver enzymes, conjugated bilirubin, and amylase/lipase.
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.

  • Performance of the test only on an outpatient basis
  • NPO status 4-6 hours before testing
  • No opiates for 4 half-lives of the drug or 6 hours prior to the study
  • Withholding other drugs which affect gallbladder motility including:
    • Calcium channel blockers
    • Octreotide
    • Progesterone
    • Indomethacin
    • Theophylline
    • Benzodiazepines
    • H2 blockers

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 dyskinesia

Performance of a HIDA scan in the absence of the symptom complex outlined above (Rome III criteria)

  • Patients with atypical symptoms who have an abnormal HIDA scan will not necessarily benefit from cholecystectomy as other etiologies (e.g. IBS, GERD, functional bowel and motility disorders) are more likely.

Failure to adequately exclude other structural diseases that could explain the symptoms

  • Although controversial, most experts recommend performance of an upper endoscopy prior to cholecystectomy for biliary dyskinesia to rule out other structural disorders of the upper GI tract (esophageal strictures, gastric and duodenal ulcers, H pylori, etc).

Performance of a HIDA scan while the patient is acutely ill or on medications that inhibit gallbladder function

  • Because of the functional nature of the HIDA scan, it is easily impacted by patient factors and should not be performed except under the conditions listed above.

Failure to obtain complete laboratory studies (liver enzymes, conjugated bilirubin, amylase/lipase)

  • In order to exclude other disorders of the liver and pancreas, all patients should have normal laboratory studies prior to making a diagnosis of biliary dyskinesia.
Treatment Options

Cholecystectomy 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 Information

For 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 Surgery

Sign up for our newsletter to get the latest clinical information, free online CME, and more.

Learn more about the University of Wisconsin Department of Surgery

We provide world class patient care, move surgery forward with innovative research, and train the next generation of surgeons.

Learn with us at one of our upcoming educational events, or refer your patients to our surgeons.

Gallbladder Problems Without Gallstones

Although gallstones are the most common cause of gallbladder disease, they’re not always the culprit. Acute acalculous gallbladder disease is a big term for something pretty simple — it simply means gallbladder disease that isn’t caused by gallstones.

Gallbladder Problems: When It’s Not Gallstones

Acalculous gallbladder disease is really quite rare. Gallbladder problems are most often attributed to gallstones or a condition called cholecystitis — a type of gallbladder disease characterized by inflammation of the gallbladder. But cholecystitis is most often caused by gallstones — as often as 90 percent of the time.

That means that fewer than 10 percent of inflamed gallbladders occur for some other reason than gallstones. And although there are other problems that can occur with the gallbladder, these two are by far the most common — acalculous gallbladder disease occurs so rarely that there aren’t readily available statistics on it.

Acute acalculous gallbladder disease “typically happens in already sick patients from other causes,” says Tomasz Rogula, MD, PhD, a staff surgeon at the Bariatric and Metabolic Institute at the Cleveland Clinic in Ohio. Most often, these people are sick with a major infection called sepsis, which is a generalized infection of the whole body. The bacteria travel through the bloodstream and eventually travel to the gallbladder, infecting it and causing inflammation.

By comparison, gallstones are a rather common malady, striking more than 25 million people in the United States — as much as 10 percent to 15 percent of the entire population. At the greatest risk are women ages 20 to 60, as up to 20 percent of them will have gallstones.

Gallbladder Problems: Acute Acalculous Gallbladder Disease Symptoms

Acute acalculous gallbladder disease, which can cause the gallbladder to become thickened and distended, is characterized by a sudden inflammation of the gallbladder wall.

Symptoms include pain that:

  • Is localized to the right upper abdominal area
  • Comes and goes
  • Is accompanied by nausea
  • Strikes after a meal, particularly one including very fatty or greasy foods

Gallbladder Problems: Treating Acute Acalculous Gallbladder Disease

If a patient complains of pain characteristic of gallbladder disease, Dr. Rogula says that an ultrasound is usually performed to check for gallstones. If they are not present, a blood test can look for bacteria in the blood that can indicate acute acalculous gallbladder disease caused by infection.

The most common treatment for acute acalculous gallbladder disease, says Rogula, is intravenous administration of antibiotics — a pill won’t typically battle this raging infection.

“Sometimes we need to drain the bile that is inside the gallbladder because the bile can be infected as well,” he adds. A tiny drain is inserted inside the gallbladder, which allows the bile to escape. Gallbladder removal surgery is very rarely used to treat acute acalculous gallbladder disease, Rogula says, but might be considered if antibiotics and drainage aren’t effective in treating the condition.

Gallbladder Problems: If Acalculous Gallbladder Disease Goes Untreated

Acute acalculous gallbladder disease isn’t something to ignore, particularly if a serious septic infection is to blame.

“It can be very dangerous if not treated,” says Rogula. The condition can lead to:

  • Complete blockage of the bile ducts
  • A perforation — a small hole — in the gallbladder, which allows bile to leak outside the gallbladder
  • Gangrene

If you’ve got suspicious pains in your upper right abdomen, it’s best to get it checked out — if it’s your gallbladder, gallstones are most likely to blame. But if they aren’t, your doctor will run tests to find out what’s troubling your gallbladder, and remedy the situation appropriately to ease your pain.

About the author

Leave a Reply

Your email address will not be published. Required fields are marked *