While surgery is a common option for those diagnosed with biliary dyskinesia, also known as functional gallbladder disorder, a researcher from West Virginia University is questioning the widespread nature of this practice due to the limited clinical research available.
Biliary dyskinesia refers to a gallbladder issue where patients do not have gallstones, yet they experience intense pain in the upper right part of their abdomen, typically triggered by fatty meals. This pain often lasts for over 30 minutes and can significantly interfere with daily activities. In the U.S., it is the leading reason for cholecystectomy, or gallbladder removal, in children, and constitutes about 10% to 20% of similar surgeries in adults.
“As the number of surgeries rises, we need to ensure they are performed based on proper indications and genuinely benefit patients. However, the data shows many gaps,” mentioned Dr. Bryan Richmond, who heads the surgery department at the WVU School of Medicine Charleston Campus. “Unlike in the U.S., cholecystectomy for this issue is not commonly accepted in other countries.”
Medical experts are still unsure of the exact causes of this disorder, but it is known to occur when the gallbladder fails to contract effectively to release bile through its ducts.
To accurately diagnose functional gallbladder disorder and determine which patients might benefit most from surgery, Richmond explained that several criteria should be assessed: experiencing biliary pain, the absence of gallstones, and a low gallbladder ejection fraction — which measures the bile released during gallbladder contractions.
Clinicians use a test called a cholecystokinin-cholescintigraphy, or CCK-HIDA scan, to measure the ejection fraction. However, Richmond noted that this test is sometimes incorrectly applied.
“The challenge lies in the fact that the scan doesn’t necessarily predict disease, as the normal and abnormal values are based on healthy individuals rather than patients experiencing pain,” he stated. “It should be evaluated in conjunction with the patient’s symptoms, combining traditional biliary symptoms with the supporting results from the scan to consider surgery.”
Richmond’s recently published paper in the journal JAMA discusses both the supporting evidence and the scarcity of it regarding the prevalence of this surgery, highlighting the need for additional research. The journal approached Richmond after his presentation on the subject at the American College of Surgeons Clinical Congress.
He referenced a 1991 study that looked into whether patients benefited from the surgery and a 2016 randomized control trial he and his team conducted to further refine the findings. Both studies indicated that patients with classic gallbladder pain symptoms, no gallstones, and a low ejection fraction had the highest likelihood of successful surgical outcomes. Still, he believes neither study alone provides sufficient justification for the surge in surgeries.
“The 1991 study included fewer than 30 patients, which is too small to justify a significant change in medical practice,” Richmond remarked. “Our trial, published in the Journal of American College of Surgeons, was also limited in size. In summary, we lack robust data to endorse this surgical practice.”
Richmond believes more extensive research with a larger participant pool is essential to ensure that surgery is the best choice based on a patient’s combination of symptoms and ejection fraction results. He anticipates that the new findings will support the previous studies conducted in 1991 and 2016.
“My next aim is to secure funding for a larger multicenter trial that gathers adequate numbers and standardizes inclusion criteria for extended follow-ups to measure surgical success versus failure,” he said. “I believe that with well-chosen patients, cholecystectomy can provide lasting relief in biliary dyskinesia. However, for patients who do not present classic symptoms, the farther away they are from these classic symptoms, the lower their chances of success.”
At present, the only management for functional gallbladder disorder is through pain relief medications and by avoiding foods that provoke discomfort. Nonetheless, until more research is performed, Richmond recommends that doctors carefully consider their surgical decisions.
“This condition isn’t dangerous or progressive; it’s fundamentally different from gallstone disease,” he advised. “It is crucial for clinicians to be transparent with patients regarding the implications of their diagnosis. If left untreated, the disorder may continue to be uncomfortable and limit lifestyle, but it doesn’t pose any significant danger, and the outcomes of cholecystectomy for this condition historically have not provided as much pain relief as seen in gallstone-related conditions.”
