Acalculous biliary pain is biliary colic without gallstones, resulting from structural or functional disorders; it is sometimes treated with laparoscopic cholecystectomy or endoscopic sphincterotomy.
(See also Overview of Biliary Function.)
Biliary colic can occur in the absence of gallstones. Acalculous biliary pain requires laparoscopic cholecystectomy in some patients. Common causes of such biliary pain include the following:
Microscopic stones (biliary sludge or microlithiasis)—not detected by routine abdominal ultrasound
Abnormal gallbladder emptying (gallbladder dyskinesia)
Biliary tract hypersensitivity
Sphincter of Oddi dysfunction (including papillary stenosis and functional gallbladder, biliary sphincter, or pancreatic sphincter disorders [1])
Hypersensitivity of the adjacent duodenum
Gallstones that have spontaneously passed
General reference
1. Cotton PB, Elta GH, Carter AR, et al. Rome IV. Gallbladder and sphincter of Oddi disorders. Gastroenterology. 2016;S0016-5085(16)00224-9, 2016. doi: 10.1053/j.gastro.2016.02.033
Diagnosis of Acalculous Biliary Pain
Ultrasound
Sometimes laboratory testing, cholescintigraphy, or endoscopic retrograde cholangiopancreatography (ERCP) with sphincter of Oddi manometry
The best diagnostic approach remains unclear.
Acalculous biliary pain is suspected in patients with biliary colic when diagnostic imaging cannot detect gallstones or structural abnormalities. Imaging should include ultrasound and, where available, endoscopic ultrasound (for small stones < 1 cm).
Abnormal laboratory tests may reveal evidence of a biliary tract abnormality (eg, elevated alkaline phosphatase, bilirubin, alanine aminotransferase, or aspartate aminotransferase) or a pancreatic abnormality (eg, elevated lipase) during an episode of acute pain. Cholescintigraphy with cholecystokinin infusion measures gallbladder emptying (ejection fraction); potentially interfering medications such as calcium channel blockers, opioids, and anticholinergics should be avoided. ERCP with biliary manometry detects papillary stenosis and sphincter of Oddi dysfunction.
Functional disorders causing acalculous biliary pain
Sphincter of Oddi dysfunction (disorders of gut-brain interaction, including functional gallbladder disorder, functional biliary sphincter disorder, and functional pancreatic sphincter disorder)—characterized by functional acalculous biliary pain—is diagnosed according to the Rome IV criteria (1, 2). All of the following criteria must be met:
Pain occurs in the epigastrium and/or right upper quadrant.
Symptoms recur at different intervals.
Pain increases to a steady degree and lasts 30 minutes or longer.
Pain is severe enough to interrupt daily activities or lead to an emergency department visit.
Pain is not significantly related to bowel movements.
Pain is not significantly relieved by postural change or acid suppression.
Supportive criteria include:
Pain with nausea and/or vomiting
Pain that radiates to the back and/or right infrascapular region
Pain that interrupts sleep
A functional gallbladder disorder is diagnosed when the Rome IV criteria are met, in the absence of cholelithiasis or a structural etiology of the pain (1). Typically, scintigraphy is abnormal or gallbladder ejection fraction is decreased.
A functional biliary sphincter of Oddi disorder is diagnosed when the Rome IV criteria are met in the absence of cholelithiasis or a structural etiology to the pain plus elevated aminotransferases or a dilated common bile duct (but not both) (1). Typically, serum pancreatic tests are normal, sphincter of Oddi manometry may be abnormal, and scintigraphy may be abnormal.
A functional pancreatic sphincter of Oddi disorder is diagnosed when the Rome IV criteria are met in patients with a history of recurrent idiopathic episodes of acute pancreatitis (typical pain with amylase or lipase > 3 times normal and/or imaging evidence of acute pancreatitis) plus no clear etiology, with negative endoscopic ultrasound imaging, and with abnormal sphincter of Oddi manometry (1).
Diagnosis references
1. Cotton PB, Elta GH, Carter AR, et al. Rome IV. Gallbladder and sphincter of Oddi disorders. Gastroenterology. 2016;150(6):1420-1249.e2. doi:10.1053/j.gastro.2016.02.033
2. Drossman DA. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features and Rome IV. Gastroenterology. Published online February 19, 2016. doi:10.1053/j.gastro.2016.02.032
Treatment of Acalculous Biliary Pain
Unclear but sometimes laparoscopic cholecystectomy or endoscopic sphincterotomy
Laparoscopic cholecystectomy may improve outcomes for patients with microscopic stones and possibly abnormal gallbladder motility (1). Otherwise, the role of laparoscopic cholecystectomy or endoscopic sphincterotomy remains unclear, as does the benefit of evaluating gallbladder emptying. Pharmacologic therapies have no proven benefit.
Treatment reference
1. Cotton PB, Elta GH, Carter CR, et al. Rome IV. Gallbladder and sphincter of Oddi disorders. Gastroenterology. 2016;150(6):1420-1249.e2. doi:10.1053/j.gastro.2016.02.033
