Biliary Dyskinesia and Symptomatic Gallstone Disease in Children: Two Sides of the Same Coin?

Abstract

Background Despite lack of consensus criteria, biliary dyskinesia (BD) is an increasingly accepted pediatric diagnosis. Aims We compared patient characteristics, outcomes, and resource utilization (before and after surgery) between children with BD and symptomatic cholecystolithiasis (LITH). Methods Data from the electronic medical record were abstracted for children diagnosed with BD or LITH between December 1, 2002, and November 30, 2012, at Children’s Hospital of Pittsburgh. Results Four hundred and ten patients were identified (BD: 213 patients, LITH: 197 patients). Patients with BD had significantly lower BMI, longer symptom duration, more dyspeptic symptoms, and were more likely to present with other symptoms. Forty-one patients (13.8 %) with BD underwent cholecystectomy despite a normal gallbladder ejection fraction (GB-EF). In 32 of these, sincalide triggered pain compared to 75 of the 155 patients with low GB-EF. After surgery, patients with BD more commonly visited gastroenterology clinics and had more GI-related hospitalizations, while emergency room visits decreased in both groups. Only the nature of biliary disease independently predicted continuing pain after surgery, which in turn was the best predictor for higher resource utilization after cholecystectomy. Conclusions A large percentage of children with BD did not meet the adult diagnostic standards. Compared to those with LITH, children with BD have more widespread symptoms and continue to use more clinical resources after surgery. These findings suggest that despite its benign prognosis, BD is increasingly treated like other potentially acute gallbladder diseases, although it has the typical phenotype of FGIDs and should be treated using approaches used in such disorders.

Trend of Pediatric Cholecystectomy: Clinical Characteristics and Indications for Cholecystectomy

“…Srinath et al [29] showed that pediatric patients with biliary dyskinesia who underwent cholecystectomy visited gastroenterology clinics more commonly and had more gastrointestinal symptom related hospitalizations than those with symptomatic cholecystolithiasis (OR 7.76, 95% CI 3.58-16.84). They insisted on treatment strategy used for other functional disorder rather than surgical approach, but the use of hepatobiliary scintigraphy is particularly of concern as it involves administration of radiopharmaceuticals to very young patients, infants, and neonates, who are at high potential risk of detrimental effects from ionizing radiation [30].…”

Black Bile of Melancholy or Gallstones of Biliary Colics: Historical Perspectives on Cholelithiasis

“…While mostly retrospective surgical reports suggest impressive success rates [119], a longitudinal cohort study demonstrated a similar rate of symptom resolution during conservative therapy in more than 80 % of patients with presumed biliary pain but no gallstones, comparable to the improvement described after surgery for symptomatic gallbladder disease [120]. Importantly, resource utilization continues to be high after cholecystectomy for biliary dyskinesia, adding more contemporary support to the cautionary notes of early investigators [7,121].…”

“…Postoperative outcomes were consistently worse compared to patients with symptomatic cholelithiasis [33,59,82,107,117,118]. Despite these concerning findings, operations for biliary dyskinesia, defined by a normal appearing gallbladder without stones, have been on the rise and account for up to 20 % of cholecystectomies in adults and even close to 50 % in children [7,8]. While mostly retrospective surgical reports suggest impressive success rates [119], a longitudinal cohort study demonstrated a similar rate of symptom resolution during conservative therapy in more than 80 % of patients with presumed biliary pain but no gallstones, comparable to the improvement described after surgery for symptomatic gallbladder disease [120].…”

“…Surgical innovation led to an increase in gallbladder operations and the lowered threshold for operative interventions [7,8], raising questions about the appropriateness of and alternatives to some of these surgeries. The goal of this review was to trace the evolution of our current understanding of and treatment for cholelithiasis with a focus on gallbladder disease rather than manifestations or complications of gallstones in the ductal system.…”

Biliary Dyskinesia in Children and Adolescents: A Mini Review

“…Once biliary dyskinesia is diagnosed, the usual treatment is cholecystectomy as there is no accepted medical treatment specific to altering gallbladder function (2,3). The rates of cholecystectomy for pediatric biliary dyskinesia continue to rise in the United States as numerous papers report positive outcomes with little to no surgical complications (4)(5)(6)(7)(8)(9)(10). Biliary dyskinesia is now among the most common conditions resulting in cholecystectomy in children and adolescents (11)(12)(13).…”