Tag Archives: biliary dyskinesia

Pediatric Experience with Presumed Biliary Dyskinesia

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A recent study (SR Matta et al. JPGN 2018; 66: 808-10) highlights the frequency of cholecystectomies for “presumed biliary dyskinesia” in the United States.

Using a nationwide inpatient database, the authors examined the indication for cholecystectomy in the pediatric population from 2002 to 2011.

Key findings:

  • During the study period, the authors identified 66,380 cholecystectomies in children.  The leading indications were calculus cholecystitis (73.6%), biliary dyskinesia (10.8%), and chronic cholecystitis without calculus.
  • The frequency of biliary dyskinesia as the indication for cholecystectomy jumped significantly during the study period, particularly the first few years: 6.6% (2002), 7.8% (2003), 9.8% (2004), 10.4% (2005 & 2006), 9.9% (2007), 11.8% (2008), 9.6% (2009), 11.9% (2010), and 10.6% (2011).
  • 75% of cases were children >12 years, and 77.5% were females.

The results from the study and the way that biliary dyskinesia is controversial are reviewed in the discussion.

  • A large proportion of biliary dyskinesia patients will develop symptoms suggestive of another functional GI disorder
  • Long-term resolution of symptoms with cholecystectomy is highly variable after surgery and “55-85% of  children with biliary dyskinesia will improve with medical management.”
  • Prospective studies are lacking, but some retrospective studies have recommended using lower cut off values for ejection fraction(eg. <15-% instead of <35%); whereas, other studies have shown no correlation between ejection fraction and outcomes.

My take: Sometimes a ‘quick fix’ is not a fix at all. As this study notes, it is difficult to rely on the diagnosis of biliary dyskinesia.  Many will improve without surgery and many develop divergent symptoms.

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Big Creek Greenway, not far from McFarland

March 2017 Briefs

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MC Montana, AS Evers. J Pediatr 2017; 181: 279-84. This commentary reviewed recent studies regarding anesthetic neurotoxicity. “Two recently published human studies suggest a lack of harm in otherwise-healthy children following a short duration anesthetic (approximately 1 hour)” References: Lancet 2016; 387: 239-50 & JAMA 2016; 315: 2312-20.

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NR Santucci et al. JPGN 2017; 64: 186-93.  This systematic review selected 31 studies (out of 916 citations) and found there is no consensus concerning diagnostic criteria for biliary dyskinesia and the data supporting the concept of biliary dyskinesia in children is weak.  The uncontrolled studies were generally observational, retrospective designs with relatively small numbers.

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I Youngster et al. J Pediatr 2017; 182: 239-44.  This study examined large prescription databases (more than 74 million person years) and identified wide discrepancy in antibiotic use among the six different countries.  For example, among children less than 2 years of age, South Korea had the highest rate of antimicrobial use, with 3.41 prescribed courses per child-year; in contrast, the rates were 1.4 in Italy, 1.5 in Spain, 1.1 in the U.S., 1.0 in Germany, and 0.5 in Norway.

A Srivastavai et al. JPGN 2017; 64: 194-9. In this retrospective study with 262 children with liver disease-related ascites, the authors found spontaneous bacterial peritonitis (or culture-negattive neurocytic ascites) in 28.6%. Half of these patients were asymptomatic.  SBP/CNNA was defined by having a polymorphonuclear leukocyte count of >250 cells/mm3.  There was a 24% one-year mortality rate for those who had SBP/CNNA.

MR Narkewicz et al. JPGN 2017; 64: 210-7. Using data from the pediatric acute liver failure group, the researchers identified a high rate of autoantibodies (28%) among 986 pediatric subjects with acute liver failure. The presence of autoantibodies was not significantly associate with 21-day outcomes and steroid treatment was not associated with survival; in fact, those without a known diagnosis of autoimmune hepatitis, had a higher risk of death with steroid therapy. In the setting of acute liver failure, autoantibody positivity does not obviate the need for a complete diagnostic workup.

A Lauterio et al. Liver Transplantation 2017; 23: 184-93.  Italian review of living donor safety found that major complications occurred in 12.6% (31 or 246)  but there were no mortalities. 5 (2%) required reoperation.

 

from Twitter's 'This Week in Church Signs' feed

from Twitter’s ‘This Week in Church Signs’ feed

Biliary Dyskinesia –“Only in America”

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In a recent commentary from Gastroenterology & Endoscopy News (http://www.gastroendonews.com), Moshe Schein reviews a recent study regarding biliary dyskinesia (BD) (Am J Surg 2015; 209: 799-803) which highlights that almost 20% of cholecystectomies in the U.S. are for noncalculous disease.

Key points:

  • The number of cholecystectomies for BD increased from 43.3 to 89.1 per 1 million between 1991-2011.
  • BD is “almost unheard of” in all other parts of the world.  “The majority of surgeons practicing outside the United States maintain that BD is a myth…Measuring gallbladder ejection fraction is something that they never do.”

My take: this is an area in need of a large randomized controlled trial.  Perhaps biliary dyskinesia will share the same fate as sphincter of Oddi dysfunction.

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Jenny Lake, Grand Tetons

Jenny Lake, Grand Tetons

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