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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 24  |  Issue : 2  |  Page : 61-64

Laparoscopic cholecystectomy for ultrasound normal gallbladders: Should we forego hepatobiliary iminodiacetic acid scans?


Centre for Rural Health Studies, Faculty of Medicine, Memorial University of Newfoundland, Canada

Date of Web Publication22-Mar-2019

Correspondence Address:
Dr. Judith Roger
Centre for Rural Health Studies, Faculty of Medicine, Memorial University of Newfoundland
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CJRM.CJRM_28_18

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  Abstract 

Introduction: Hepatobiliary iminodiacetic acid (HIDA)-radionuclear scans are used to diagnose biliary dyskinesia, the treatment for which is a laparoscopic cholecystectomy (LC). However, the predictive value of the HIDA scan for LC candidacy is debated.
Case: A physical, ultrasound, and blood test for a 53-year-old woman with biliary dyskinesia-like symptoms were normal, contradicting a textbook history. A HIDA-scan was ordered but the results suggested she was not eligible for a LC. The patient insisted on receiving the procedure and gave informed consent to undergo an elective LC.
Results: Six-weeks post-surgery, the patient's symptoms had ceased besides one short episode of abdominal pain.
Conclusion: A LC relieved the patient's symptoms, suggesting that negative HIDA-scans can mislead correct decisions to perform a LC. Surgeons who receive inconclusive HIDA scan results should consult their patients, and when necessary and agreed-upon, take an informed risk together in an attempt to improve the patient's quality of life.

  Abstract in French 

Introduction: La scintigraphie hépatobiliaire avec acide iminodiacétique (HIDA) radionucléaire sert au diagnostic de dyskinésie biliaire, qui est traitée par cholécystectomie par laparoscopie. La valeur prédictive de l'HIDA pour identifier les candidats à la cholécystectomie par laparoscopie fait cependant l'objet d'un débat.
Cas: L'examen physique, l'échographie et les analyses sanguines d'une femme de 53 ans qui présentait des symptômes évoquant la dyskinésie étaient normaux, ce qui contredisait l'anamnèse modèle. Une scintigraphie HIDA a été réalisée, mais les résultats ont laissé croire que la patiente était inadmissible à la cholécystectomie par laparoscopie. La patiente a insisté pour subir l'intervention et a donné son consentement éclairé pour subir une cholécystectomie par laparoscopie non urgente.
Résultats: Six semaines après l'intervention, les symptômes de la patiente étaient disparus, à l'exception d'un épisode de douleur abdominale.
Conclusion: La cholécystectomie par laparoscopie a soulagé les symptômes de la patiente, ce qui laisse croire que la scintigraphie HIDA négative peut entraîner des erreurs de décision pour réaliser une cholécystectomie par laparoscopie. Les chirurgiens qui reçoivent des résultats inconcluants à la scintigraphie HIDA doivent consulter leurs patients, et lorsque nécessaire et entendu, prendre ensemble un risque éclairé pour tenter d'améliorer la qualité de vie des patients.
Mots-clés: Dyskinésie biliaire, scintigraphie HIDA, cholécystite alithiasique, cholécystite chronique sans lithiases, dysfonctionnement biliaire, vésicules biliaires symptomatiques échographie normale

Keywords: Biliary dyskinesia, HIDA scan, acalculous cholecystitis, chronic cholecystitis without stones, gallbladder dysfunction, symptomatic ultrasound normal gallbladders


How to cite this article:
Roger J, Heeley T, Graham W, Walsh A. Laparoscopic cholecystectomy for ultrasound normal gallbladders: Should we forego hepatobiliary iminodiacetic acid scans?. Can J Rural Med 2019;24:61-4

How to cite this URL:
Roger J, Heeley T, Graham W, Walsh A. Laparoscopic cholecystectomy for ultrasound normal gallbladders: Should we forego hepatobiliary iminodiacetic acid scans?. Can J Rural Med [serial online] 2019 [cited 2019 Jun 26];24:61-4. Available from: http://www.cjrm.ca/text.asp?2019/24/2/61/254795


  Introduction Top


Biliary pain in the absence of objective laboratory or radiologic findings such as ultrasound is referred to as biliary dyskinesia.[1] The incidence of this symptom complex (estimated as 8% in men and 21% in women[2]) is almost as unclear[3] as the test used to detect it: the hepatobiliary iminodiacetic acid (HIDA)-radionuclear scan. The predictive value of HIDA scans is debated. When faced with a patient with a typical history and a normal ultrasound, we wonder whether we are doing justice to a patient living in a remote part of our country by ordering a test which may not change the ultimate decision: to operate or not.[4],[5] This case underscores the unreliability of the HIDA scan for indicating laparoscopic cholecystectomy (LC) candidacy.


  Case Report Top


A 53-year-old woman presented to a rural surgical clinic in Western Newfoundland complaining of severe, intermittent epigastric pain radiating to the back and occurring periodically about once weekly for several years. The discomfort was provoked by consuming foods such as bacon or eggs and was associated with epigastric burning, bloating, and belching which would last for 1–2 h. She described feeling completely well between the attacks. Three years prior, the patient had been seen for an upper gastrointestinal (GI) endoscopy and stomach biopsy for Helicobacter pylori. These tests were normal. Her symptoms had been temporarily improved with proton-pump inhibitors. She was a non-smoker, non-drinker with a history of two normal deliveries and a bladder repair. She had chronic low back pain. Her physical examination was normal. Even the Murphy's sign, which would make the gallbladder a prime suspect, was negative. Routine bloodwork such as complete blood count, electrolytes, liver functions, including bilirubin and amylase, ultrasound, and the HIDA scan were all normal. A repeat upper GI endoscopy with an attempt to aspirate bile from the duodenum did not reveal any bile crystals. Likewise, a colonoscopy was normal. A barium meal revealed mild reflux. The small bowel motility was normal.

After explaining to the patient that there was no objective evidence of a symptomatic gallbladder, despite a textbook history suggesting the opposite, she insisted that something needed to be done to relieve her symptoms. “If I had a knife, I would take it out myself. My uncle and my mother both had their gallbladders out. One of their ultrasounds was normal as well”. Given the congruency of the clinical history and the relatively low risk of any complication being less than 2%,[6] the patient was given a choice to undergo a LC. She provided informed consent to undergo the operation, which occurred without complications. The intra-abdominal organs looked fine and the gallbladder was normal, even on the subsequent pathology report.

During a 6-week follow-up appointment, the patient reported that her pain and burping had ceased, though interestingly, she was more constipated, an unusual symptom after cholecystectomy. She had experienced one short episode of abdominal pain, mostly gas trapping. Otherwise, her symptoms were relieved.


  Discussion Top


Over the years, the lead author (JR) has often encountered this scenario and discussed it with prominent surgeons and gastroenterologists. Most (usually the older ones) agree that it is reasonable to operate after exhausting all possible investigations and informing the patient. However, many were still reluctant to do so based on history only; despite agreeing that something needs to be done, we wondered if we ordered enough preoperative investigations to take that educated leap. This paper presents one such case where every attempt was made to determine the most appropriate course of action, but ultimately, the test results were not conducive to a LC, despite the patient's symptoms and history being textbook for this surgery.

A typical history involves intermittent severe right upper quadrant pain radiating to the right shoulder after fatty meals; a Murphy's sign on physical examination makes the gallbladder the prime suspect. On the other hand, an atypical history might include reflux, or 'dyspepsia', associated with nightly epigastric burning and pain of a milder nature alleviated by antacids, H2-blockers. Basic bloodwork ensues, and some practitioners may prescribe H2-blockers. If symptoms do not improve despite avoiding non-steroidal anti-inflammatory drugs, and alcohol, and especially, if factors like unintentional weight loss or anaemia are present, an upper GI endoscopy ensues. This could show inflammation of the upper GI tract down to the duodenum, erosions, ulcers, and even a hiatus hernia or (rarely) tumors.

Confronted with an atypical scenario, we consider GI causes, for example, irritable bowel, celiac disease and intestinal bacterial growth, musculoskeletal problems – radicular pain T6–T10, scoliosis and spondylosis and vascular – intestinal claudication and unstable angina.

If we suspect the gallbladder to be malfunctioning (typical history), despite a normal ultrasound, we may order a HIDA scan. If the HIDA scan results are normal, then the opinions of surgeons are divided. Some colleagues prefer to proceed only if they find an objective abnormality. Inquisitive diagnosis, while important, is second to caring for the patients, communities, and societies to which we are accountable as healthcare providers.[7] Listening to our patients is the key to quality care. Faced with inconclusive HIDA scan results, the surgeon can leave the diagnosis in no man's land and the patient's needs unaddressed or empathise with their needs and take an informed risk together in an attempt to improve the patient's quality of life. Is it not better to try something than do nothing? To offer any avenue for relief than turning our backs on the patient? Is this not in the spirit of socially accountable medicine?

The literature about the usefulness of the HIDA scan is controversial.[5],[8],[9] Yet, in 2015, the largest retrospective study of 438 patients showed[8] that in case of typical symptoms, the HIDA scan is inferior as a method of predicting post-operative pain relief (66% with positive scan and 77% with negative = normal scan).

In 2007, 4% (48 patients) of 1201 patients[10] with biliary colic had normal ultrasounds and endoscopy results. Thirty-five of these patients received positive HIDA scans and went on to have LCs. Thirty-one reported symptom alleviation or improvement at the 6-week post-operative mark. Of the remaining 13 patients who had inconclusive HIDA scans, 6 went on to have a LC with full symptom relief. Although the HIDA scan proved to be accurate for the 31 patients who improved, performing a LC with an inconclusive HIDA scan was still effective for an additional 6 patients. One of the normal HIDA scan patients later presented with acute cholecystitis.

The Rome IV consensus conference[11] about functional gallbladder disorder emphasises the typical biliary history as the strongest predictor for post-operative success. While recommending a HIDA scan should be done, the conference recognises that many studies of the cholecystokinin radionuclear scans ejection fraction are inconclusive and of poor quality.

Of course in acute cholecystitis, the HIDA scan is superior to abdominal ultrasound.[12]

Experts are divided on the HIDA scan's use for diagnosing biliary dyskinesia.[7] The lead author's own unpublished results from a practice-based quality improvement (QI) study [Table 1] show that only one of 12 patients reported no post-operative improvement when contacted by an impartial third person about their sentiments regarding the operation. That is, the HIDA scan does not appear to predict surgical success and might as well be a coin flip that has no place in today's era of fiscal responsibility. Investigations that ultimately do not impact our decision to operate are an inefficient, frivolous use of healthcare funds that, particularly for rural patients, is an impetus for unnecessary long-distance travel. Why gamble when you can listen to the patient?
Table 1: Unpublished quality improvement findings

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Although post-cholecystectomy syndrome (PCS)[13] is a recognized symptom complex varying in frequency between 6-47% of patients after LC for symptomatic gallstones, none of the studies of LC for biliary dyskinesia reported any adverse events. The worst outcome was a nonresolution of symptoms.

Since JR's original, unpublished QI study, she has treated 60 more patients with a LC for biliary dyskinesia. Future research will follow up with patients to check the typical history (length, type and severity of symptoms) pre- and post-surgery to determine if a LC, performed despite a normal HIDA scan, results in symptom relief.

Financial support and sponsorship: Nil.

Conflicts of interest: There are no conflicts of interest.

 
  References Top

1.
Toouli J. Biliary dyskinesia. Curr Treat Options Gastroenterol 2002;5:285-91.  Back to cited text no. 1
    
2.
Hansel SL, DiBaise JK. Functional gallbladder disorder: Gallbladder dyskinesia. Gastroenterol Clin North Am 2010;39:369-79, x.  Back to cited text no. 2
    
3.
Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: Cholelithiasis and cancer. Gut Liver 2012;6:172-87.  Back to cited text no. 3
    
4.
Ponsky TA, DeSagun R, Brody F. Surgical therapy for biliary dyskinesia: A meta-analysis and review of the literature. J Laparoendosc Adv Surg Tech A 2005;15:439-42.  Back to cited text no. 4
    
5.
Eckenrode AH, Ewing JA, Kotrady J, Hale AL, Smith DE. HIDA scan with ejection fraction is over utilized in the management of biliary dyskinesia. Am Surg 2015;81:669-73.  Back to cited text no. 5
    
6.
Available from: https://riskcalculator.facs.org/RiskCalculator/index.jsp. [Last accessed on 2018 Dec 19].  Back to cited text no. 6
    
7.
Whitcomb ME. What does it mean to be a physician? Acad Med 2007;82:917-8.  Back to cited text no. 7
    
8.
Nilesh A, Patel M, Jason J. Therapeutic efficacy of laparoscopic cholecystectomy in the treatment of biliary dyskinesia. The Am J of Surg 2004;187:209-12.  Back to cited text no. 8
    
9.
Huffman JL, Schenker S. Acute acalculous cholecystitis: A review. Clin Gastroenterol Hepatol 2010;8:15-22.  Back to cited text no. 9
    
10.
Riyad K, Chalmers CR, Aldouri A, Fraser S, Menon K, Robinson PJ, et al. The role of (99m) technetium-labelled hepato imino diacetic acid (HIDA) scan in the management of biliary pain. HPB (Oxford) 2007;9:219-24.  Back to cited text no. 10
    
11.
Cotton PB, Elta GH, Carter CR, Pasricha PJ, Corazziari ES. Gallbladder and sphincter of oddi disorders. Gastroenterology 2016;150:1420-9.  Back to cited text no. 11
    
12.
Kaoutzanis C, Davies E, Leichtle SW, Welch KB, Winter S, Lampman RM, et al. Is hepato-imino diacetic acid scan a better imaging modality than abdominal ultrasound for diagnosing acute cholecystitis? Am J Surg 2015;210:473-82.  Back to cited text no. 12
    
13.
Girometti R, Brondani G, Cereser L, Como G, Del Pin M, Bazzocchi M, et al. Post-cholecystectomy syndrome: Spectrum of biliary findings at magnetic resonance cholangiopancreatography. Br J Radiol 2010;83:351-61.  Back to cited text no. 13
    



 
 
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