Acalculous Cholecystopathy

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.

Treatment
Medical Care: No effective medical treatment for acalculous cholecystopathy exists.

Surgical Care:

• Laparoscopic cholecystectomy is indicated for the treatment of biliary dyskinesia after all of the other conditions in the differential diagnosis have been ruled out with a reasonable degree of certainty. The procedure usually is performed as an outpatient operation.

• Intraoperative cholangiography is performed at the discretion of the operating surgeon.

Consultations: Gastroenterologists and surgeons are the consultants usually involved in the care of these patients. Most patients are evaluated and treated as outpatients.

Diet: No specific dietary restrictions are applicable. Avoiding foods that exacerbate symptoms, typically fatty or spicy foods, temporarily may diminish some of the symptoms.

Activity: No restrictions on activity are applicable.

Medication

No effective medical treatment for acalculous cholecystopathy exists.