Tag Archives: gallbladder ejection fraction

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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Quirky HIDA Study Shows That HIDA Scans Not Too Helpful

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As noted in a previous post, Biliary Dyskinesia –“Only in America” | gutsandgrowth, gallbladder dykinesia is a quite dubious diagnosis.  A recent pediatric study (PM Jones et al. JPGN 2016; 63: 71-75) adds to the uncertainty.

This study utilized a large database for a retrospective review of HIDA scans in patients <22 years.  In a group of 2558 patients, 310 patients had a full-text gallbladder pathology report paired with HIDA scan. The majority of these HIDA scans (64.5%) were performed in teenage Caucasian girls.  Key finding:

  • Gallbladder ejection fraction (GBEF) did not correlate with the presence of gallbladder pathology.  The Odd Ratio (OR) for cholecystitis with EF of 16-34 was 0.98.
  • The majority had at least microscopic pathology: 71.6% had microscopic cholecystitis

The authors indicate that other studies have shown that the diagnosis of gallbladder dyskinesia is controversial “because some point to the strong placebo effect of a surgical intervention, as well as the finding that patients who were observed for a year or more had similar symptom improvement  compared with those who had an operation.” [J Pediatric Surg 2006; 41: 1894-8]

Ultimately, the utility of HIDA scans can only be addressed with randomized prospective studies. Perhaps, these studies will show that HIDA scans are not predictive of who needs a cholecystectomy.

My take: It is interesting that pathology did not correlate with HIDA results.  However, the bigger question is whether abnormal gallbladder function, as assessed by HIDA, triggers symptoms that merit cholecystectomy. This is not addressed by this study.

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