Acalculous Biliary Pain

The best diagnostic approach remains unclear.

Acalculous biliary pain is suspected in patients with biliary colic when diagnostic imaging Imaging Tests of the Liver and Gallbladder Imaging is essential for accurately diagnosing biliary tract disorders and is important for detecting focal liver lesions (eg, abscess, tumor). It is limited in detecting and diagnosing diffuse... read more cannot detect gallstones. Imaging should include ultrasonography and, where available, endoscopic ultrasonography (for small stones < 1 cm).

Abnormal laboratory tests Laboratory Tests of the Liver and Gallbladder Laboratory tests are generally effective for the following: Detecting hepatic dysfunction Assessing the severity of liver injury Monitoring the course of liver diseases and the response to treatment... read more 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 Cholescintigraphy Imaging is essential for accurately diagnosing biliary tract disorders and is important for detecting focal liver lesions (eg, abscess, tumor). It is limited in detecting and diagnosing diffuse... read more with cholecystokinin infusion measures gallbladder emptying (ejection fraction); potentially interfering drugs such as calcium channel blockers, opioids, and anticholinergics should not be used. ERCP Endoscopic retrograde cholangiopancreatography (ERCP) Imaging is essential for accurately diagnosing biliary tract disorders and is important for detecting focal liver lesions (eg, abscess, tumor). It is limited in detecting and diagnosing diffuse... read more with biliary manometry detects papillary stenosis and sphincter of Oddi dysfunction.

Sphincter of Oddi dysfunction (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 Diagnosis reference Acalculous biliary pain is biliary colic without gallstones, resulting from structural or functional disorders; it is sometimes treated with laparoscopic cholecystectomy or endoscopic sphincterotomy... read more ). All of the following criteria must be met:

Supportive criteria include:

A functional gallbladder disorder is diagnosed when the Rome IV criteria are met, in the absence of cholelithiasis Cholelithiasis Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder. Gallstones tend to be asymptomatic. The most common symptom is biliary colic; gallstones do not cause dyspepsia... read more or a structural etiology of the pain. 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). 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.

Laparoscopic cholecystectomy Laboratory Tests of the Liver and Gallbladder Laboratory tests are generally effective for the following: Detecting hepatic dysfunction Assessing the severity of liver injury Monitoring the course of liver diseases and the response to treatment... read more improves outcomes for patients with microscopic stones and possibly abnormal gallbladder motility. Otherwise, the role of laparoscopic cholecystectomy or endoscopic sphincterotomy remains unclear. Pharmacologic therapies have no proven benefit.