RUQ Pain and a Normal RUQ Pain and a Normal Abdominal UltrasoundAbdominal Ultrasound

Furqaan Ahmad;Evan L.FogelFurqaan Ahmad;Evan L.FogelPublished:12/02/2008Published:12/02/2008

From Clinical Gastroenterology and Hepatology

Clinical Scenario Clinical Scenario 

A 30-year-old woman is referred for A 30-year-old woman is referred for evaluation of a 1-year history of evaluation of a 1-year history of intermittent, debilitating, postprandialintermittent, debilitating, postprandial right upper quadrant pain associated right upper quadrant pain associated with with nauseanausea and occasional vomitingand occasional vomiting. . The pain can last from 30 minutes to 2 The pain can last from 30 minutes to 2 hours, often radiates to the upper hours, often radiates to the upper back, and is not associated with bowel back, and is not associated with bowel movements or exercise. movements or exercise.

Clinical Scenario Clinical Scenario 

The patient denies a history of weight The patient denies a history of weight loss, fever, chills, change in urine or loss, fever, chills, change in urine or stool color, or jaundice. She denies stool color, or jaundice. She denies significant alcohol use. Trials of significant alcohol use. Trials of antacids, proton pump inhibitors, and antacids, proton pump inhibitors, and antispasmodics have not been helpful. antispasmodics have not been helpful. At times the pain has been severe At times the pain has been severe enough to interrupt her daily activities. enough to interrupt her daily activities.

Clinical Scenario Clinical Scenario 

The patient reports that liver The patient reports that liver chemistries and amylase and lipase chemistries and amylase and lipase levels have been persistently levels have been persistently normal.ultrasound reveals a normal-normal.ultrasound reveals a normal-appearing gallbladder without appearing gallbladder without gallbladder wall thickening or gallbladder wall thickening or gallstones. bile ducts are not dilated. gallstones. bile ducts are not dilated. The liver and limited views of the The liver and limited views of the pancreas are also unremarkable. The pancreas are also unremarkable. The patient underwent an endoscopy(EGD) patient underwent an endoscopy(EGD) 1 month ago that was normal. 1 month ago that was normal.

What is the most likely cause What is the most likely cause for this patient's symptoms? for this patient's symptoms?

What is the next step in the What is the next step in the diagnostic evaluation of this diagnostic evaluation of this patient?patient?

The Problem The Problem 

The right upper quadrant pain in The right upper quadrant pain in this patient is suggestive of this patient is suggestive of biliary origin. However, this pain biliary origin. However, this pain syndrome accompanied by a syndrome accompanied by a normal gallbladder ultrasound normal gallbladder ultrasound and normal liver function tests and normal liver function tests suggests subtle suggests subtle acalculous acalculous gallbladder disease. gallbladder disease.

Differential diagnosis:Differential diagnosis:

peptic ulcer disease, peptic ulcer disease, choledocholithiasis and microlithiasis,choledocholithiasis and microlithiasis, pancreatobiliary neoplasia,pancreatobiliary neoplasia, irritable bowel syndrome, irritable bowel syndrome, musculoskeletal painmusculoskeletal pain Type III sphincter of Oddi dysfunction Type III sphincter of Oddi dysfunction

(SOD)(SOD)

The pathophysiology of The pathophysiology of acalculous gallbladder acalculous gallbladder

pain :pain :

I.I. primary disorder of gallbladder primary disorder of gallbladder motilitymotility: entrapment of : entrapment of supersaturated cholesterol crystals supersaturated cholesterol crystals in the gallbladder wall, impaired in the gallbladder wall, impaired response to cholecystokinin (CCK), response to cholecystokinin (CCK), or intrinsic defects in the or intrinsic defects in the gallbladder musculature.gallbladder musculature.

II.II. Visceral hypersensitivity:Visceral hypersensitivity: (biliary (biliary dyskinesia) analogous to that in dyskinesia) analogous to that in other functional disorders of the other functional disorders of the gastrointestinal tract. gastrointestinal tract.

Diagnostic Criteria for…Diagnostic Criteria for…

Functional Gallbladder DisordersFunctional Gallbladder Disorders 1.Episodes of pain lasting 30 minutes or longer1.Episodes of pain lasting 30 minutes or longer 2.Recurrent symptoms occurring at varying 2.Recurrent symptoms occurring at varying

intervals (not daily)intervals (not daily) 3.Gradual buildup of pain intensity to a steady 3.Gradual buildup of pain intensity to a steady

levellevel 4.The pain is severe enough to interrupt the 4.The pain is severe enough to interrupt the

patient's activities.patient's activities. 5.The pain is not relieved by bowel 5.The pain is not relieved by bowel

movements.movements. 6.The pain is not relieved by postural changes.6.The pain is not relieved by postural changes.

Diagnostic criteria…Diagnostic criteria…

7.The pain is not relieved by antacids.7.The pain is not relieved by antacids. 8.Structural diseases that could explain the 8.Structural diseases that could explain the

patient's symptoms have been excluded.patient's symptoms have been excluded. The pain might present with 1 or more of the The pain might present with 1 or more of the

following supportive criteria: following supportive criteria: 1.Pain associated with nausea and vomiting1.Pain associated with nausea and vomiting 2.Pain radiates to the back and/or right 2.Pain radiates to the back and/or right

subscapular region.subscapular region. 3.Pain awakens patient from sleep in the 3.Pain awakens patient from sleep in the

middle of the night.middle of the night.

Diagnosis:Diagnosis:

99mtechnetium-labeled hepato-99mtechnetium-labeled hepato-iminodiacetic acid (99mTcHIDA) iminodiacetic acid (99mTcHIDA) cholescintigraphycholescintigraphy HIDA scan HIDA scan

A low ejection fraction(less than 40%) is indicative of gallbladder dysfunction.

Cholescintigraphy Cholescintigraphy 

Measurements of gallbladder ejection Measurements of gallbladder ejection fraction are influenced by the fraction are influenced by the dose, rate,dose, rate, and duration of CCKand duration of CCK infusioninfusion, none of , none of which are currently standardized.. which are currently standardized..

a a uniform thresholduniform threshold for abnormal for abnormal gallbladder ejection fraction cannot be gallbladder ejection fraction cannot be standardized without uniform standardized without uniform administration of CCK. Most published administration of CCK. Most published data have defined gallbladder dysfunction data have defined gallbladder dysfunction as an ejection fraction less than 35%–as an ejection fraction less than 35%–40%. pain.40%. pain.

Cholescintigraphy Cholescintigraphy 

The finding of HIDA scan is not 100% The finding of HIDA scan is not 100% specific for gallbladder dysfunction. specific for gallbladder dysfunction. Several other conditions might also Several other conditions might also cause impaired emptying, including cause impaired emptying, including obesity, diabetes,obesity, diabetes, pregnancy, pregnancy, cirrhosis, celiac disease, and cirrhosis, celiac disease, and medications (calcium channel medications (calcium channel blockers,blockers, opioids, anticholinergics, opioids, anticholinergics, and sex hormone)and sex hormone)

Outcomes After Outcomes After Cholecystectomy :Cholecystectomy :

The patients that have abnormal The patients that have abnormal HIDAscan recommended cholesystectomy HIDAscan recommended cholesystectomy but the benefit of surgery in relief of pain but the benefit of surgery in relief of pain of patients of patients is contraversy.is contraversy.

studiesstudies:partial relief after removal of a :partial relief after removal of a dysfunctional gallbladder in some dysfunctional gallbladder in some patients.patients.

AA study:study:similar responses to surgery in similar responses to surgery in patients both with and without abnormal patients both with and without abnormal gallbladder emptying gallbladder emptying

Cholecystectomy :Cholecystectomy :

The mean follow-up period of the studies The mean follow-up period of the studies included in the meta-analysis by Ponsky included in the meta-analysis by Ponsky and colleagues ranged from and colleagues ranged from 9–30 9–30 monthsmonths . .

Outcome of study:Outcome of study: patients who patients who underwent surgery had a high rate of underwent surgery had a high rate of symptomatic response to surgery at symptomatic response to surgery at 1-1-month follow-upmonth follow-up. However, at . However, at 2-year 2-year follow-upfollow-up, the proportion of patients with , the proportion of patients with symptomatic improvemen tsymptomatic improvemen twas similar was similar among those who underwent surgery and among those who underwent surgery and those who did not. those who did not.

Sphincter of Oddi Sphincter of Oddi Dysfunction :Dysfunction :

This classically presents as This classically presents as recurrent or continued upper recurrent or continued upper quadrant pain after quadrant pain after cholecystectomy .cholecystectomy .

(1) does SOD occur in patients with an intact (1) does SOD occur in patients with an intact gallbladder?gallbladder? (2) is there an association between SOD and (2) is there an association between SOD and gallbladder dysfunction? gallbladder dysfunction?

SOD with an intact SOD with an intact gallbladder?gallbladder?

There are limited data on the frequency There are limited data on the frequency of SOD in patients with an intact of SOD in patients with an intact gallbladder. However, SOD has been gallbladder. However, SOD has been documented in up to 10% of patients documented in up to 10% of patients with symptomatic gallstones and 50% of with symptomatic gallstones and 50% of patients with biliary-type pain and a patients with biliary-type pain and a normal gallbladder ultrasound. normal gallbladder ultrasound.

association between SOD association between SOD and gallbladder and gallbladder dysfunction? dysfunction?

In a prospective study conducted to In a prospective study conducted to study the relationship between SOD and study the relationship between SOD and gallbladder dysfunction, gallbladder dysfunction, 81 patients81 patients with biliary-type pain and an intact, with biliary-type pain and an intact, sonographically normal gallbladder sonographically normal gallbladder underwent both sphincter of Oddi underwent both sphincter of Oddi manometry and HIDA cholescintigraphy. manometry and HIDA cholescintigraphy. Of Of 41 patients41 patients with a normal HIDA scan, with a normal HIDA scan, 57%57% had SOD; of had SOD; of 40 patients40 patients with an with an abnormal HIDA scan, abnormal HIDA scan, 50%50% had SOD. had SOD.

Data from this study suggest Data from this study suggest that both SOD and gallbladder that both SOD and gallbladder dysfunction are common in this dysfunction are common in this group of patients and group of patients and appear to appear to occur independently of one occur independently of one another.another.

Algorithm Algorithm

ofof

patientspatients

withwith

RUQ painRUQ pain

&&

NormalNormal

sonographysonography..