The hallmark of acalculous cholecystopathy, frequently called biliary dyskinesia, is recurrent right upper quadrant pain in the absence of gallstones. Acalculous cholecystitis refers to cholecystitis without gallstones. Patients frequently undergo extensive, often invasive and expensive, testing before receiving definitive therapy.
Surgeons typically label acalculous cholecystopathy as biliary dyskinesia. For gastroenterologists, biliary dyskinesia is a synonym for sphincter of Oddi dysfunction.
The incidence of acalculous cholecystopathy is unknown. The condition occurs more frequently in females than males and in individuals aged 40-60 years. In general, 10-15% of patients undergoing laparoscopic cholecystectomy have biliary dyskinesia.
In a study from a West European trauma unit, 10% of patients with severe multiple injuries developed cholecystitis requiring cholecystectomy. This included acute acalculous cholecystitis in about 40%, chronic acalculous cholecystitis in 40% and cholecystitis with cholecystolithiasis in 20%.
The presentation is highly variable – with or without right upper quadrant pain and tenderness, fever, leukocytosis, elevated liver enzymes and lipase or amylase – and may be similar to that of acute calculous cholecystitis. Nausea is the most commonly associated symptom, although vomiting is unusual.
When pain is present, it characteristically occurs in the right upper quadrant 30-60 minutes after meals, usually lasts 1-4 hours, typically does not radiate, and is often exacerbated by greasy and spicy foods.
Other gastrointestinal symptoms suggest diagnoses other than acalculous cholecystopathy. Acute cholecystitis may occur as a complication of critical illness, such as sepsis or cardiovascular disease.
The physical examination is directed toward ruling out other possible etiologies of the pain. However, usually, there are no abnormal physical examination findings associated with acalculous cholecystopathy, although mild right upper quadrant tenderness may occur.
No specific laboratory studies for acalculous cholecystopathy exist. Instead, the studies help rule out other conditions that are part of the differential diagnosis.
- Liver profile – To rule out hepatitis, acute cholecystitis, and choledocholithiasis.
- CBC – To rule out acute inflammation as observed in cases of hepatitis or acute cholecystitis.
- Helicobacter pylori serology – Helpful in ruling out causes of gastritis and peptic ulcer disease.
Ultrasonography is most useful to rule out conditions in the differential diagnosis, as results are usually normal in patients with acalculous cholecystopathy.
No effective medical treatment of acalculous cholecystopathy exists. Some authors suggest that in patients with acute acalculous cholecystitis without overt peritonitis, antibiotics may be useful before cholecystectomy.
Gastroenterologists and surgeons are the specialists usually involved in the care of these patients. Patients undergoing surgical therapy have been reported to be 2.8 times more likely to have symptomatic relief versus nonoperative therapy.
Laparoscopic cholecystectomy is indicated for the treatment of biliary dyskinesia. The procedure is usually performed as an outpatient operation.
Complications of acalculous cholecystopathy are those related to cholecystectomy. In addition to the morbidities inherent in any procedure (eg, bleeding, infection, damage to adjacent structures), several morbidities are unique to laparoscopic cholecystectomy. The rate of bile duct injury is approximately 3 cases per 1000 procedures.
Complications related to carbon dioxide pneumoperitoneum, such as acidosis and shoulder pain, may also occur. These complications usually resolve rapidly in most healthy patients.
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.
The main pitfall is failure to consider and evaluate the patient for other conditions in the differential diagnosis, especially malignancy.
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