Ocala Regional Medical Center
Functional gallbladder disorder (FGBD) is increasingly being recognized as an etiology of Biliary colics. it is characterized by typical biliary pain without an evidence of gallbladder stones, sludge or microcrystals. It is a rare disorder compared to other functional gastrointestinal (GI) disorders. it accounts for only 2% to 5% of all laparoscopic cholecystectomies.
Methods: 45 year old male presented with right upper quadrant (RUQ) pain for 1 day. Pain is progressive, colicky, 8/10 in severity with diffuse radiation, not related to food, no aggravating or alleviating factors, no associated nausea or vomiting. last bowel movement 1 day prior was formed with no blood, black stools. Patient denied fever, recent travel. He reported prior similar but less severe episode. On presentation, patient was afebrile, heart rate 104. tenderness to palpation in RUQ, negative Murphey's sign. Lab work was noted for leukocytosis 19.1 thou/mm3, normal hemoglobin and normal lipase. CT of abdomen and pelvis showed relatively decompressed GB. Ultrasonography of the RUQ showed fatty liver with no evidence of cholelithiasis, GB wall thickening nor pericholecystic fluid. Patient was started on supportive measures, however, the pain and the leukocytosis persisted for 2 days. Hepatobiliary scintigraphy was performed.it showed gallbladder ejection fraction of 3%. General surgery was consulted. robotic cholecystectomy showed dilated GB and early acute cholecystitis. After surgery, the symptoms resolved and WBCs trended down to normal range.
Discussion: FGBD, previously known as biliary dyskinesia, is a motility disorder, it may be due to GB muscle dysfunction or metabolic disorder that affects the mobility of the GI tract– as it is often associated with abnormal gastric emptying and colon transit- leading to ineffective bile recycling within the GB.
FGBD is a diagnosis of exclusion. Hence the importance of Rome IV criteria; symptom-based diagnostic criteria in the absence of GB stones, including: RUQ or epigastric biliary pain that lasts at least 30 minutes, occurs at different intervals, severe enough to interrupt daily activities or results in emergency department visit, not related to bowel movements, and not relieved with postural changes or acid suppression. Other supportive criteria include: normal liver function, normal amylase and lipase, and low ejection fraction on scintigraphy < 35-40. it is worthy emphasizing that application of Rome IV criteria as the key for successful management.
Figure 1: 1A) Right upper quadrant ultrasound showing GB with no evidence of gallstones, gallbladder wall thickening, or pericholecystic fluid collection. 1B) CT abdomen/pelvis without contrast showing a relatively decompressed gallbladder
Figure 2: Hepatobiliary scintigraphy w/ ejection fraction with Cholecystokinin stimulation showing 2A) GBEF at 10 minutes = 1%, 2B) GBEF at 20 minutes = 4%, 2C) GBEF at 30 minutes = 3%
Randa Abdelmasih indicated no relevant financial relationships.
Ramy Abdelmaseih indicated no relevant financial relationships.
Mohammed Ansari indicated no relevant financial relationships.
Anamarys Blanco indicated no relevant financial relationships.