Cholecystectomy for Biliary Dyskinesia in Gastroparesis
Cholecystectomy for Biliary Dyskinesia in Gastroparesis
Objectives Biliary dyskinesia and gastroparesis are associated with upper abdominal discomfort and dyspeptic symptoms in the absence of structural abnormalities. We hypothesized that the similarity in symptoms would trigger testing and surgical treatment for biliary abnormalities in a significant number of patients, with refractory symptoms ultimately demonstrating impairment of gastric function.
Methods The study was designed as a retrospective review of patients seen between April 1, 2008 and December 31, 2009. Patients were identified using diagnosis code for gastroparesis (International Classification of Diseases, Ninth Revision code 536.3). Demographic information, duration, etiology and severity of disease, coexisting psychiatric illness, pain and functional gastrointestinal disorders, medication use, and abdominal surgery with a focus on cholecystectomy were abstracted from the medical records.
Results A total of 131 patients were identified. Women predominated (77.86%), and the idiopathic form of gastroparesis was the most common etiology. A total of 59 (45%) patients had undergone cholecystectomies. Although symptomatic cholelithiasis was the primary indication, more than one-third of these patients underwent surgery for biliary dyskinesia (n = 19) or chronic acalculous cholecystitis (n = 2). In this subgroup, improvement was either absent (n = 13) or transient only (n = 8), lasting for 1.0 ± 0.6 months. Patients who underwent cholecystectomy were younger compared with the rest of the group; all other variables did not show significant differences.
Conclusions Considering the overlap and correlation between gastric and gallbladder function, we should raise the threshold for biliary dyskinesia and reassess the appropriateness of surgical therapy, especially in patients with coexisting dyspeptic symptoms.
Despite advances in our understanding of underlying mechanisms, gastroparesis remains an often difficult-to-treat disorder, with a significant impact on the quality of life of affected individuals. Even if the diagnosis has been established, continuing symptoms lead to repeated testing, which has a relatively low diagnostic yield. Pain is the most common reason physicians give when ordering additional tests, such as computed tomography or endoscopy. Although previously discounted as being an important symptom in gastroparesis, pain is the prevalent symptom reported in many studies since 1998. Abdominal pain and other postprandial symptoms certainly characterize other structural and functional disorders, ranging from peptic ulcer disease to pancreatitis. Because most patients with gastroparesis undergo extensive testing to exclude underlying structural problems within the gastrointestinal tract, the symptomatic overlap affects mostly patients with functional illnesses. One study showed that 90% of patients with idiopathic gastroparesis met the diagnostic criteria for functional dyspepsia. Conversely, approximately one-third of patients with functional dyspepsia will have delayed gastric emptying. Biliary dyskinesia comprises a controversial group of disorders, characterized by abdominal pain and abnormalities in gallbladder or sphincter of Oddi function. Descriptions typically refer to biliary-type pain, which should be intermittent and located in the epigastric area or the right upper quadrant, with possible radiation to the back, right shoulder, or subscapular region. As is true for functional dyspepsia, symptoms overlap with those of gastroparesis, thus leaving the assessment of biliary and gastric function the primary defining difference. We have observed a high likelihood of operative interventions in patients with gastroparesis, with cholecystectomy being the most common abdominal surgery. At least in patients with diabetes mellitus, impaired gastric function correlates with lower gallbladder ejection fraction. Based on these findings, we hypothesized that the similarity in symptoms would lead to testing of biliary function, with the diagnosis of coinciding impairment of gallbladder function leading to the diagnosis of biliary dyskinesia and cholecystectomy in a significant number of patients.
Abstract and Introduction
Abstract
Objectives Biliary dyskinesia and gastroparesis are associated with upper abdominal discomfort and dyspeptic symptoms in the absence of structural abnormalities. We hypothesized that the similarity in symptoms would trigger testing and surgical treatment for biliary abnormalities in a significant number of patients, with refractory symptoms ultimately demonstrating impairment of gastric function.
Methods The study was designed as a retrospective review of patients seen between April 1, 2008 and December 31, 2009. Patients were identified using diagnosis code for gastroparesis (International Classification of Diseases, Ninth Revision code 536.3). Demographic information, duration, etiology and severity of disease, coexisting psychiatric illness, pain and functional gastrointestinal disorders, medication use, and abdominal surgery with a focus on cholecystectomy were abstracted from the medical records.
Results A total of 131 patients were identified. Women predominated (77.86%), and the idiopathic form of gastroparesis was the most common etiology. A total of 59 (45%) patients had undergone cholecystectomies. Although symptomatic cholelithiasis was the primary indication, more than one-third of these patients underwent surgery for biliary dyskinesia (n = 19) or chronic acalculous cholecystitis (n = 2). In this subgroup, improvement was either absent (n = 13) or transient only (n = 8), lasting for 1.0 ± 0.6 months. Patients who underwent cholecystectomy were younger compared with the rest of the group; all other variables did not show significant differences.
Conclusions Considering the overlap and correlation between gastric and gallbladder function, we should raise the threshold for biliary dyskinesia and reassess the appropriateness of surgical therapy, especially in patients with coexisting dyspeptic symptoms.
Introduction
Despite advances in our understanding of underlying mechanisms, gastroparesis remains an often difficult-to-treat disorder, with a significant impact on the quality of life of affected individuals. Even if the diagnosis has been established, continuing symptoms lead to repeated testing, which has a relatively low diagnostic yield. Pain is the most common reason physicians give when ordering additional tests, such as computed tomography or endoscopy. Although previously discounted as being an important symptom in gastroparesis, pain is the prevalent symptom reported in many studies since 1998. Abdominal pain and other postprandial symptoms certainly characterize other structural and functional disorders, ranging from peptic ulcer disease to pancreatitis. Because most patients with gastroparesis undergo extensive testing to exclude underlying structural problems within the gastrointestinal tract, the symptomatic overlap affects mostly patients with functional illnesses. One study showed that 90% of patients with idiopathic gastroparesis met the diagnostic criteria for functional dyspepsia. Conversely, approximately one-third of patients with functional dyspepsia will have delayed gastric emptying. Biliary dyskinesia comprises a controversial group of disorders, characterized by abdominal pain and abnormalities in gallbladder or sphincter of Oddi function. Descriptions typically refer to biliary-type pain, which should be intermittent and located in the epigastric area or the right upper quadrant, with possible radiation to the back, right shoulder, or subscapular region. As is true for functional dyspepsia, symptoms overlap with those of gastroparesis, thus leaving the assessment of biliary and gastric function the primary defining difference. We have observed a high likelihood of operative interventions in patients with gastroparesis, with cholecystectomy being the most common abdominal surgery. At least in patients with diabetes mellitus, impaired gastric function correlates with lower gallbladder ejection fraction. Based on these findings, we hypothesized that the similarity in symptoms would lead to testing of biliary function, with the diagnosis of coinciding impairment of gallbladder function leading to the diagnosis of biliary dyskinesia and cholecystectomy in a significant number of patients.
