Biliary Dyskinesia

What is biliary dyskinesia? Biliary dyskinesia is a functional disorder that mostly affects your gallbladder. Sometimes it affects the small muscle (sphincter) located where bile from your gallbladder empties into your small intestine. A functional disorder is a problem with the way the organ or muscle functions. (It's different from a mechanical blockage, like a gallstone.) The main function of your gallbladder is to store bile made by your liver and pass it on to your small intestine to help with digestion. When it’s time to digest, your small intestine signals to your gallbladder through hormones. Your gallbladder contracts to push bile out into the bile ducts that will deliver it to your small intestine. Biliary dyskinesia is a breakdown in these functions. Somewhere along the way, something isn’t working right. The problem might be related to the hormonal signaling, to the nerves that are supposed to receive the signal or to the muscles that are supposed to react. It's difficult for healthcare providers to tell which it is at first, but they can tell that your gallbladder isn’t ejecting enough bile.

How does biliary dyskinesia affect my body? When your gallbladder can’t efficiently move bile out into your bile ducts, the backup of bile causes your gallbladder to become fuller or swollen (distended). This is similar to when there’s a blockage of your gallbladder by a gallstone. The swelling of your gallbladder and the retained bile within it can cause infections, inflammation (cholecystitis) and pain. You may feel intermittent upper abdominal pain that comes and goes and nausea, especially after eating when your gallbladder tries to contract. This is called biliary colic. In addition, not having enough bile in your intestine can cause abdominal bloating, nausea, vomiting and improper digestion, especially after eating fatty foods. Conventional wisdom has been that biliary pain is almost always caused by gallstones (cholelithiasis). But healthcare providers are beginning to realize this may not be the case. In fact, biliary dyskinesia is becoming increasingly recognized as a common cause of gallbladder disease. It often affects older children, as well as adults.

Who gets biliary dyskinesia? Functional gallbladder disorders have only recently become more recognized and reported, particularly in the U.S. We don’t know yet if this trend is unique to the U.S., if biliary dyskinesia is actually becoming more common or just more recognized. It’s not clear if specific people are more likely than others to be affected. But having obesity and diabetes might be risk factors. Having obesity is known to affect your metabolism in a variety of ways. It can lead to fat storage in your organs and encourages chronic inflammation. Both of these factors affect gallbladder motility (how your gallbladder moves). Static bile can become condensed and sludgy, which leads to gallstones. Having obesity is a known risk factor for gallstones, but gallstones may be secondary to biliary dyskinesia.

What does gallbladder dyskinesia feel like?

Most people feel gallbladder pain in the area where their gallbladder is — in the upper right quadrant of their abdomen, under their right rib cage. But some people feel it in the middle of their abdomen, and others feel it in their right shoulder or back. It occurs in episodes that last up to several hours. The pain builds steadily over the first 20 minutes and then gradually begins to decline.

Episodes occur intermittently, but not every day. They're most common after eating, especially fatty or rich meals. This is when the gallbladder is supposed to contract to release the bile into your intestine. The pain is generally severe enough to interrupt your activities. It may wake you up in the middle of the night or send you to the emergency room. Nausea and vomiting are also common.

What are the symptoms of biliary dyskinesia?

Typical symptoms of biliary dyskinesia include:

- Upper right quadrant abdominal pain.

- Episodic pain that builds to a peak.

- Bloated stomach.

- Nausea and vomiting.

- Unintended weight loss.

Some people also report:

- Headaches.

- Fatigue.

- Chronic acid reflux.

- Functional indigestion and/or IBS.

- Anxiety and/or depression.

What causes biliary dyskinesia?

For the most part, healthcare providers don’t know what causes motility disorders. Sometimes, specific nerves (like the vagus nerve) don’t work as they should. But in most cases, it’s impossible to know exactly where the problem is. Sometimes, a more generalized metabolic disorder or a motility disorder of the intestines can affect specific motility of your gallbladder or biliary sphincter.

How is biliary dyskinesia diagnosed?

- Functional disorders like biliary dyskinesia are diagnosed in several steps. Healthcare providers must:

- Confirm that your symptoms indicate biliary pain, and not some other type of abdominal pain.

- Confirm that you don’t have another, more specific type of biliary disease, such as gallstones.

- Confirm that your gallbladder isn’t ejecting enough bile.

- Confirm that your symptoms occur when your gallbladder contracts.

- Confirm that medications or other factors aren’t affecting your gallbladder motility.

Symptom check

They’ll begin by asking you about your symptoms and looking for the signature features of biliary colic. These criteria include:

- Pain that occurs in your upper abdomen, usually on the right side.

- Pain that recurs intermittently in episodes that last at least 30 minutes.

- Pain builds up to a steady level that’s moderate to severe.

- Pain isn’t relieved by vomiting, bowel movements, posture changes or antacids.

- Episodes have been occurring regularly for at least three months.

Disease check

Once your healthcare provider has confirmed that your symptoms meet these criteria, they’ll look to exclude other common causes of biliary pain. They’ll take:

- Blood tests to check pancreatic enzyme and liver enzyme levels. High enzyme levels could indicate a problem with one of these organs or a backup of bile (especially high bilirubin).

- An abdominal ultrasound to look at your gallbladder and bile ducts. They’ll look for structural causes of biliary pain, like gallstones, gallbladder wall thickening or bile duct dilation.

Gallbladder function check

If your blood tests and ultrasound come back normal, the next step will be to test your gallbladder function. Healthcare providers do this with a type of nuclear medicine imaging test called a HIDA scan. During the test, a technician injects a radioactive isotope (a tracer) into your vein. The tracer travels through your biliary system, and a computer scanner reads it and produces images on a screen.

To check your gallbladder function, healthcare providers add another step to the test called a cholecystokinin check. Cholecystokinin is the hormone that tells your gallbladder to contract and eject bile into your bile ducts. Your technician will inject cholecystokinin into your vein and follow up with another series of images as your gallbladder contracts. They’ll observe and take measurements.

Your healthcare provider will ask you to confirm that you feel biliary pain when your gallbladder contracts. They’ll also measure your gallbladder “ejection fraction,” which is how much bile your gallbladder ejects when it contracts. If your ejection fraction is less than 40%, and if no medications or hormone therapies can explain your reduced gallbladder motility, they’ll diagnose gallbladder biliary dyskinesia.

In rare cases, your provider may run a very specialized test to measure how well the muscle at the junction between your bile duct and intestine opens in response to your body’s signals. This test is only available in specific centers. Your provider inserts a special endoscope into your mouth under sedation, similar to an upper endoscopy or EGD. Then, they advance the endoscope into the first portion of your small intestine and measure the relaxation of your sphincter of Oddi.

Often, providers can only diagnose malfunction of the sphincter of Oddi once all the other causes of motility disorders of the biliary tree are excluded. Sometimes, they even make the diagnosis after the gallbladder has been removed and the person treated had no resolution of their symptoms.

Does biliary dyskinesia go away?

There isn’t evidence that biliary dyskinesia can go away on its own. Generally, biliary dyskinesia isn’t diagnosed until you’ve had symptoms for at least three months. Usually, by this time, no one wants to continue to wait for it to go away by itself. If it does, it likely wasn’t really a functional disorder but another type of motility disorder that was caused by temporary factors.

How do you fix biliary dyskinesia?

The only known effective treatment for gallbladder biliary dyskinesia is gallbladder removal (cholecystectomy). This is usually a minimally invasive surgery (laparoscopic surgery), and you can usually go home the same day. Laparoscopic surgery uses small, keyhole incisions that heal quickly and leave less scarring and pain. You can live well without your gallbladder. Your liver will now send bile directly to your small intestine.

If your healthcare provider determines that the motility disorder is in the sphincter muscle, this muscle can be widened or opened with an endoscopic procedure. This procedure is usually done after your gallbladder is removed and the symptoms persist. In fact, not only is it difficult to diagnose the sphincter dysfunction, but it’s also rare that the motility disorder is only in your sphincter. Often your gallbladder is affected as well.

What are the side effects of cholecystectomy?

Your digestive system will take a few weeks to adjust to the lack of a gallbladder. During this time, you may have difficulties digesting fats. Most healthcare providers recommend that you adjust your diet temporarily to prevent discomfort from indigestion. Avoid fried and fatty foods at first, and be careful with fiber. Reintroduce whole grains, vegetables and legumes slowly to prevent gas and bloating.