INTRODUCTION	Section 2 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Background: The hallmark of acalculous cholecystopathy, frequently called biliary dyskinesia, is recurrent right upper quadrant pain in the absence of gallstones. Patients frequently undergo extensive, often invasive and expensive, testing prior to receiving definitive therapy. Although the treatment of choice is laparoscopic cholecystectomy, the rates of symptomatic improvement are not as favorable as in patients with biliary colic and gallstones.

Surgeons typically label acalculous cholecystopathy biliary dyskinesia. For gastroenterologists, biliary dyskinesia is a synonym for sphincter of Oddi dysfunction, which is a distinct disease process. This article discusses only acalculous cholecystopathy.

Pathophysiology: Acalculous cholecystopathy is a clinical condition characterized by biliary colic-type pain in the absence of gallstones. The exact pathophysiology is unknown but likely is due to an abnormal gallbladder motility that possibly causes a relative obstruction of the cystic duct.

Frequency:

• In the US: The true incidence of acalculous cholecystopathy is unknown. With the advent of laparoscopic cholecystectomy, data suggesting an increased rate of cholecystectomy exist. In general, 10-15% of patients undergoing laparoscopic cholecystectomy have biliary dyskinesia.

• Internationally: No specific data on the incidence of biliary dyskinesia outside of the United States exist.

Mortality/Morbidity: The mortality and morbidity of acalculous cholecystopathy are related to the invasive diagnostic tests that frequently are performed and to the treatment of the condition (ie, cholecystectomy). Biliary dyskinesia does not progress to more serious conditions, such as acute cholecystitis.

Race: No data regarding racial distribution exist.

Sex: As with calculous biliary disease, acalculous cholecystopathy occurs more frequently in females than in males.

Age: As with calculous disease, most patients with acalculous cholecystopathy are aged 40-60 years.

	CLINICAL	Section 3 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

History:

• Pain

• Characteristically occurs in the right upper quadrant 30-60 minutes after meals

• Usually lasts 1-4 hours and typically does not radiate

• Often exacerbated by greasy and spicy foods

• Nausea is the most commonly associated symptom.

• Vomiting is unusual.

• Other gastrointestinal symptoms suggest diagnoses other than acalculous cholecystopathy.

Physical:

• The physical examination is directed toward ruling out other possible etiologies of the pain.

• No abnormal physical examination findings usually are associated with acalculous cholecystopathy.

• Mild right upper quadrant tenderness may occur.

Causes:

• A number of hormones have prokinetic or inhibitory effects on gallbladder motility.

• The hormones stimulating gallbladder contraction include cholecystokinin (CCK), gastrin, secretin, and motilin.

• Vasoactive inhibitory peptide, somatostatin, and pancreatic polypeptide inhibit gallbladder motility.

• Histamine stimulates contraction via histamine 1 (H1) receptors and relaxation via histamine 2 (H2) receptors.

• Of these hormones, only somatostatin is used as a therapeutic agent. The actions of somatostatin appear to be due to the inhibition of CCK-mediated gallbladder emptying.

• The increased incidence of calculous and acalculous biliary disease in females suggests an association with female sex hormones.

• Abnormalities in gallbladder emptying are especially pronounced during pregnancy.

• Although estrogen and progesterone receptors have been found in the gallbladder, no direct effects of these hormones on gallbladder contractility have been elucidated.