Acalculous biliary pain is biliary colic without gallstones, resulting from structural or functional disorders; it is sometimes treated with laparoscopic cholecystectomy.
Biliary colic can occur in the absence of gallstones, particularly in young women. Acalculous biliary pain accounts for up to 15% of laparoscopic cholecystectomies. Common causes of such biliary pain include the following:
Some patients eventually develop other functional GI disorders.
Acalculous biliary pain is suspected in patients with biliary colic when diagnostic imaging cannot detect gallstones. Imaging should include ultrasonography and, where available, endoscopic ultrasonography (for small stones < 1 cm). Abnormal laboratory tests may reveal evidence of a biliary tract abnormality (eg, elevated alkaline phosphatase, bilirubin, ALT, or AST) or a pancreatic abnormality (eg, elevated lipase) during an episode of acute pain. Cholescintigraphy with cholecystokinin infusion measures gallbladder emptying (ejection fraction); potentially interfering drugs such as Ca channel blockers, opioids, and anticholinergics should not be used. ERCP with biliary manometry detects sphincter of Oddi dysfunction. The best diagnostic approach remains problematic.
Laparoscopic cholecystectomy improves outcomes for patients with microscopic stones and possibly abnormal gallbladder motility. The role of laparoscopic cholecystectomy or endoscopic sphincterotomy remains problematic. Drug therapies have no proven benefit.
Postcholecystectomy syndrome is occurrence of abdominal symptoms after cholecystectomy.
Postcholecystectomy syndrome occurs in 5 to 40% of patients. It refers to presumed gallbladder symptoms that continue or that develop after cholecystectomy or to other symptoms that result from cholecystectomy. Removal of the gallbladder, the storage organ for bile, normally has few consequences on biliary tract function or pressures. In about 10%, biliary colic appears to result from functional or structural abnormalities of the sphincter of Oddi, resulting in altered biliary pressures or heightened sensitivity.
The most common symptoms are dyspepsia or otherwise nonspecific symptoms rather than true biliary colic. Papillary stenosis, which is rare, is fibrotic narrowing around the sphincter, perhaps caused by trauma and inflammation due to pancreatitis, instrumentation (eg, ERCP), or prior passage of a stone. Other causes include a retained bile duct stone, pancreatitis, and gastroesophageal reflux.
Patients with postcholecystectomy pain should be evaluated as indicated for extrabiliary as well as biliary causes. If the pain suggests biliary colic, alkaline phosphatase, bilirubin, ALT, amylase, and lipase should be measured, and ERCP with biliary manometry or biliary nuclear scanning should be done. Elevated liver enzymes suggest sphincter of Oddi dysfunction; elevated amylase and lipase suggest dysfunction of the sphincter's pancreatic portion.
Dysfunction is best detected by biliary manometry done during ERCP, although ERCP has a risk of inducing pancreatitis. Manometry shows increased pressure in the biliary tract when pain is reproduced. A slowed hepatic hilum-duodenal transit time on a scan also suggests sphincter of Oddi dysfunction. Diagnosis of papillary stenosis is based on a clear-cut history of recurrent episodes of biliary pain and abnormal liver (or pancreatic) enzyme tests.
Endoscopic sphincterotomy can relieve recurrent pain due to sphincter of Oddi dysfunction, especially if due to papillary stenosis. It is controversial for patients who have postcholecystectomy pain and no objective abnormalities.
Last full review/revision December 2007 by Eldon A. Shaffer, MD