Negative impact of prolonged fasting on gallbladder ejection fraction measurement with cholescintigraphy in Chronic Acalculous Symptomatic hyPERkinetic (CASPER) gallbladders
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Abstract
Background: Chronic Acalculous Symptomatic hyPERkinetic (CASPER) gallbladder is a novel clinical condition. Criteria for diagnosis include biliary symptoms in the absence of gallstones but with a high gallbladder ejection fraction on cholescintigraphy (HIDA scan). Most studies use an ejection fraction above 80% as a cut-off for a gallbladder hyperkinesia diagnosis, but variations in cholescintigraphy methodology can affect the reading. Here, we report a previously undescribed effect where longer fasting times diminish the ejection fraction in gallbladder hyperkinesia patients, that could be explained by presumable gallbladder overdistention that impedes contraction.
Methods: We report a retrospective series of 7 patients whose clinical presentation was suspicious for symptomatic gallbladder hyperkinesia, based on 12 most common symptoms and signs of gallbladder hyperkinesia that we previously identified, but whose gallbladder ejection fraction was less than 80%. We recognized that these 7 patients had all been fasted overnight prior to cholescintigraphy. We therefore repeated cholescintigraphy with only 4 to 6 hours of fasting.
Results: The repeat cholescintigraphy showed a 94% increase in mean ejection fraction from 46.5% to 90.3% when fasting time was shorter, compared to initial cholescintigraphy done with overnight fasting (Paired t-test, p = 0.0017). Six of the 7 patients opted for cholecystectomy and showed substantial symptom improvement and abnormal pathologic findings. One patient with manageable symptoms opted for medical management with dietary control.
Conclusions: Gallbladder ejection fractions from cholescintigraphy done after overnight fasting are diminished and thus misrepresent gallbladder contractility in gallbladder hyperkinesia patients. Cholescintigraphy using shorter fasting times provides more consistent data on gallbladder contractility in these cases. National guidelines for cholescintigraphy need redefinition, especially in the context of gallbladder hyperkinesia.
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References
2. Pillenahalli Maheshwarappa R, Menda Y, Graham MM, Boukhar SA, Zamba GKD, Samuel I. Association of gallbladder hyperkinesia with acalculous chronic cholecystitis: A case-control study. Surgery. 2020;168(5):800-8. doi: 10.1016/j.surg.2020.06.005.
3. TheRomeFoundation.Org. Appendix a: Rome iv diagnostic criteria for functional gastro-intestinal disorders - e) gallbladder and sphincter of odi disorder. Available from: https://theromefoundation.org/rome-iv/rome-iv-criteria/. (Accessed February 14, 2024)
4. Cotton PB, Elta GH, Carter CR, Pasricha PJ, Corazziari ES. Rome iv. Gallbladder and sphincter of oddi disorders. Gastroenterology. 2016;150:1420-9. doi: 10.1 053/j.gastro.2016. 02.033.
4. TheRomeFoundation.org. Rome v, disorders of gut-brain interaction 5th edition. Available from: https://theromefoundation.org/rome-iv/rome-v/. (Accessed February 14, 2024)
6. Kartik A, Jorge IA, Webb C, Lim ES, Chang YH, Madura J. Defining biliary hyperkinesia and the role of cholecystectomy. J Am Coll Surg. 2023;237(5):706-10. doi: 10.1097/XCS. 0000000000000793.
7. Saurabh S, Green B. Is hyperkinetic gallbladder an indication for cholecystectomy? Surg Endosc. 2019;33(5) :1613-7. doi: 10.100 7/s00464-018-6435-2.
8. Alexida L, Tiesenga FM. Laparoscopic cholecystectomy for biliary dyskinesia in patient with an extended spectrum of ejection fraction on hepatobiliary iminodiacetic acid scan. International Archives of Integrated Medicine. 2017;4(11):14-7.
9. Greenberg JJ. What is biliary hyperkinesia? Global Surgery. 2018;4(1):1-3. doi: 10.15761/ gos.1000174.
10. Ziessman HA. Sincalide: A review of clinical utility, proper infusion methodology, and alternative cholecystogogues. J Nucl Med Technol. 2019;47(3):210-2. doi: 10.2967/ jnmt.119.226019.
11. Krishnamurthy GT, Brown PH. Comparison of fatty meal and intravenous cholecystokinin infusion for gallbladder ejection fraction. J Nucl Med. 2002;43(12):1603-10.
12. Ziessman HA, Fahey FH, Hixson DJ. Calculation of a gallbladder ejection fraction: Advantage of continuous sincalide infusion over the three-minute infusion method. J Nucl Med. 1992;33(4):537-41.
13. Ziessman HA. Cholecystokinin cholescintigraphy: Clinical indications and proper methodology. Radiol Clin North Am. 2001;39(5):997-1006, ix. doi: 10.1016/s0033-8389(05)70325-0.
14. Tulchinsky M, Ciak BW, Delbeke D, et al. Snm practice guideline for hepatobiliary scintigraphy 4.0. J Nucl Med Technol. 2010; 38(4):210-8. doi: 10.2967/jnmt.110.082289.
15. Bartel TB, Juweid ME, Ponto JA, Graham MM. Corn oil emulsion: A simple cholecystagogue for diagnosis of chronic acalculous cholecystitis. J Nucl Med. 2005;46( 1):67-74.
16. Richmond BK, DiBaise J, Ziessman H. Utilization of cholecystokinin cholescintigraphy in clinical practice. J Am Coll Surg. 2013;217(2 ):317-23. doi: 10.1016/j.jamcollsurg.2013.02.034.
17. Ziessman HA, Tulchinsky M, Lavely WC, et al. Sincalide-stimulated cholescintigraphy: A multicenter investigation to determine optimal infusion methodology and gallbladder ejection fraction normal values. J Nucl Med. 2010;51(2):277-81. doi: 10.2967/jn umed.109.069393.
18. Ziessman HA. Hepatobiliary scintigraphy in 2014. J Nucl Med. 2014;55(6):967-75. doi: 10.2967/jnumed.113.131490.
19. DiBaise JK, Richmond BK, Ziessman HH, et al. Cholecystokinin-cholescintigraphy in adults: Consensus recommendations of an interdisciplinary panel. Clin Gastroenterol Hepatol. 2011;9(5):376-84. doi: 10.1016/j.cgh .2011.02.013.
20. DuCoin C, Faber R, Ilagan M, Ruderman W, Wier D. Normokinetic biliary dyskinesia: A novel diagnosis. Surg Endosc. 2012;26(11) :3088-93. doi: 10.1007/s00464-012-2342-0.
21. Srivastava A, Sood A, Joy PS, et al. Principles of physics in surgery: The laws of mechanics and vectors physics for surgeons-part 2. Indian J Surg. 2010;72(5):355-61. doi: 10.1007/s12262-010-0155-8.
22. Basford JR. The Law of Laplace and its relevance to contemporary medicine and rehabilitation. Arch Phys Med Rehabil. 2002;8 3(8):1165-70. doi: 10.1053/apmr.2002.33985.
23. Srivastava A, Sood A, Joy SP, Woodcock J. Principles of physics in surgery: The laws of flow dynamics physics for surgeons - part 1. Indian J Surg. 2009;71(4):182-7. doi: 10.1007/ s12262-009-0064-x.
24. Whitaker LF, Bosley ME, Refugia JM, et al. Outcomes after laparoscopic cholecystectomy in hyperkinetic biliary dyskinesia. Am Surg. 20 22;88(8):1983-7. doi: 10.1177/00031348211023390.
25. Eltyeb HA, Al-Leswas D, Abdalla MO, Wayman J. Systematic review and meta-analyses of cholecystectomy as a treatment of biliary hyperkinesia. Clin J Gastroenterol. 2021;14(5):1308-17. doi: 10.1007/s12328-021-01463-x.
26. Nasri B, Glass T, Singh K, Saxe J. Biliary hyperkinesia: An indication for cholecystectomy? Surg Endosc. 2021;35( 7):3244-8. doi: 10.1007/s00464-020-07757-4.
27. Williford ML, Fay KT, Simpson FJ, et al. Optimal management of the hyperkinetic gallbladder: A comparison of outcomes between operative and nonoperative approaches. Am Surg. 2021;87(6):903-9. doi: 10.1177/000 3134820966283.
28. Dekonenko C, Sujka JA, Dorman RM, Oyetunji TA, St Peter SD. Self-reported outcomes after cholecystectomy for pediatric hyperkinetic biliary dyskinesia. J Surg Res. 2020;246:73-7. doi: 10.1016/j.jss.2019.06.088.
29. Wright RC, Thach N, Peffer H, Robles R, Wright RJ. Surgical outcome in patients with biliary colic and atypical workup findings. Am J Surg. 2019;217(5):986-9. doi: 10.1016/j.amjs urg.2019.03.017.
30. Gazzetta J, Fan B, Bonner P, Galante J. Cholecystectomy for biliary hyperkinesia. Am Surg. 2019;85(2):219-22.
31. Lindholm EB, Alberty JB, Hansbourgh F, Upp JR, Lopoo J. Hyperkinetic gallbladder: An indication for cholecystectomy? Am Surg. 2013;79(9):882-4.
32. Huckaby L, Timmapuri S, Prasad R. Biliary hyperkinesia: A potentially surgically correctable disorder in adolescents. Journal of Pediatric Surgery Case Reports. 2013;1(9):3 14-6. doi: 10.1016/j.epsc.2013.08.010.
33. Yap L, Wycherley AG, Morphett AD, Toouli J. Acalculous biliary pain: Cholecystectomy alleviates symptoms in patients with abnormal cholescintigraphy. Gastroenterology. 1991;101(3):786-93. doi: 10.1016/0016-5085(91)90540-2.
34. Krishnamurthy GT, Bobba VR, Kingston E. Radionuclide ejection fraction: A technique for quantitative analysis of motor function of the human gallbladder. Gastroenterology. 1981;80(3):482-90.