ORIGINAL ARTICLE - Patient selection for cholecystectomy based on oral fatty meal augmented cholescintigraphy in cases with chronic acalculous biliary pain: Is it really that reliable?

Background: Gallstones disease associated with biliary symptoms such as gallbladder dyspepsia (episgastric discomfort, flatulence, intermittent nausea with fat intolerance), and biliary colic (abdominal pain localised in the right upper quadrant) is commonly treated by cholecystectomy. In contrast, biliary symptoms in the absence of gallstones (acalculous biliary symptoms, ABS) often constitute a diagnostic and management challenge. Decision to recommend cholecystectomy to patients with ABS is sometimes based on abnormal cholescintigram, indicating biliary dyskinesia. Recently, the radiological protocol has changed from using intravenous stimulant to oral fatty meal to augment gallbladder contraction. Objectives: To determine the long-term outcome of patients with ABS who underwent cholecystectomy based on abnormal cholescintigraphy using a new radiological protocol of oral fatty meal augmentation of the gallbladder. Methods and Statistical analysis: A retrospective study of cholecystectomy was undertaken of all patients with ABS who were investigated with a fatty meal-augmented hepatic iminodiacetic acid (HIDA) scans between 1998 and 2001. Their case notes were reviewed. Pearson chi-squared test (SPSS Version 10.0.7 standard Version. SPSS incorporated 1989–1999) was used to analyse the relation between various parameters. Results: Overall, 43 patients had HIDA scans. About 37 out of 43 (86%) patients had abnormal cholescintigrams, but only 25 were recommended surgery. Four patients were excluded owing to cholelithiasis. Sixteen patients (64%) were considered cured 6 weeks later. However, nine (36%) patients failed to improve with surgery after an average follow up of 33 weeks. Out of the 12 patients with abnormal HIDA scans who were managed conservatively, 5 (42%) recovered spontaneously, and 7 (58%) remained unchanged. Conclusion: Oral fatty meal augmented HIDA scans may be helpful in selecting patients with ABS for surgery. However, surgeons should be cautious of a potentially high false-positive rate, leaving at least a third of patients with persistent pain after surgery.

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