1. RUQ Pain and a Normal Abdominal Ultrasound Furqaan Ahmad;Evan L.Fogel Published:12/02/2008 From Clinical Gastroenterology and Hepatology

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

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

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

5. What is the most likely cause for this patient's symptoms? What is the next step in the diagnostic evaluation of this patient?

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

7. Differential diagnosis:  peptic ulcer disease,  choledocholithiasis and microlithiasis,  pancreatobiliary neoplasia,  irritable bowel syndrome,  musculoskeletal pain  Type III sphincter of Oddi dysfunction (SOD)

8. The pathophysiology of acalculous gallbladder pain : I. primary disorder of gallbladder motility: entrapment of supersaturated cholesterol crystals in the gallbladder wall, impaired response to cholecystokinin (CCK), or intrinsic defects in the gallbladder musculature. II. Visceral hypersensitivity: (biliary dyskinesia) analogous to that in other functional disorders of the gastrointestinal tract.

9. Diagnostic Criteria for… Functional Gallbladder Disorders 1.Episodes of pain lasting 30 minutes or longer 2.Recurrent symptoms occurring at varying intervals (not daily) 3.Gradual buildup of pain intensity to a steady level 4.The pain is severe enough to interrupt the patient's activities. 5.The pain is not relieved by bowel movements. 6.The pain is not relieved by postural changes.

10. 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 patient's symptoms have been excluded. 8.Structural diseases that could explain the patient's symptoms have been excluded.  The pain might present with 1 or more of the following supportive criteria: 1.Pain associated with nausea and vomiting 1.Pain associated with nausea and vomiting 2.Pain radiates to the back and/or right subscapular region. 2.Pain radiates to the back and/or right subscapular region. 3.Pain awakens patient from sleep in the middle of the night. 3.Pain awakens patient from sleep in the middle of the night.

11. Diagnosis: 99mtechnetium-labeled hepato- iminodiacetic acid (99mTcHIDA) cholescintigraphy HIDA scan 99mtechnetium-labeled hepato- iminodiacetic acid (99mTcHIDA) cholescintigraphy HIDA scan A low ejection fraction(less than 40%) is indicative of gallbladder dysfunction.

12. Cholescintigraphy Measurements of gallbladder ejection fraction are influenced by the dose, rate, and duration of CCK infusion, none of which are currently standardized.. Measurements of gallbladder ejection fraction are influenced by the dose, rate, and duration of CCK infusion, none of which are currently standardized.. a uniform threshold for abnormal gallbladder ejection fraction cannot be standardized without uniform administration of CCK. Most published data have defined gallbladder dysfunction as an ejection fraction less than 35%–40%. pain. a uniform threshold for abnormal gallbladder ejection fraction cannot be standardized without uniform administration of CCK. Most published data have defined gallbladder dysfunction as an ejection fraction less than 35%–40%. pain.

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

14. Outcomes After Cholecystectomy :  The patients that have abnormal HIDAscan recommended cholesystectomy but the benefit of surgery in relief of pain of patients is contraversy.  studies:partial relief after removal of a dysfunctional gallbladder in some patients.  A study:similar responses to surgery in patients both with and without abnormal gallbladder emptying

15. Cholecystectomy : The mean follow-up period of the studies included in the meta-analysis by Ponsky and colleagues ranged from 9–30 months. The mean follow-up period of the studies included in the meta-analysis by Ponsky and colleagues ranged from 9–30 months. Outcome of study: patients who underwent surgery had a high rate of symptomatic response to surgery at 1-month follow-up. However, at 2-year follow-up, the proportion of patients with symptomatic improvemen twas similar among those who underwent surgery and those who did not. Outcome of study: patients who underwent surgery had a high rate of symptomatic response to surgery at 1-month follow-up. However, at 2-year follow-up, the proportion of patients with symptomatic improvemen twas similar among those who underwent surgery and those who did not.

16. Sphincter of Oddi Dysfunction : This classically presents as recurrent or continued upper quadrant pain after cholecystectomy. This classically presents as recurrent or continued upper quadrant pain after cholecystectomy. (1) does SOD occur in patients with an intact gallbladder? (2) is there an association between SOD and gallbladder dysfunction?

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

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

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

20. Algorithmofpatients with with RUQ pain RUQ pain &Normalsonography.