Merck Manual

Please confirm that you are a health care professional

honeypot link

Acalculous Biliary Pain

By

Christina C. Lindenmeyer

, MD, Cleveland Clinic

Last full review/revision Sep 2021| Content last modified Sep 2021
Click here for Patient Education

Acalculous biliary pain is biliary colic without gallstones, resulting from structural or functional disorders; it is sometimes treated with laparoscopic cholecystectomy or endoscopic sphincterotomy.

Biliary colic can occur in the absence of gallstones Cholelithiasis Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder. In developed countries, about 10% of adults and 20% of people > 65 years have gallstones. Gallstones tend... read more Cholelithiasis , particularly in young women. Acalculous biliary pain accounts for up to 15% of laparoscopic cholecystectomies. Common causes of such biliary pain include the following:

Diagnosis of Acalculous Biliary Pain

  • Unclear

  • Usually ultrasonography and sometimes cholescintigraphy and/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 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 Imaging Tests of the Liver and Gallbladder 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 Cholescintigraphy 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 Endoscopic retrograde cholangiopancreatography (ERCP) 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—are 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:

  • 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 Cholelithiasis Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder. In developed countries, about 10% of adults and 20% of people > 65 years have gallstones. Gallstones tend... read more Cholelithiasis 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.

Diagnosis reference

Treatment of Acalculous Biliary Pain

  • Unclear but sometimes laparoscopic cholecystectomy or endoscopic sphincterotomy

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. Drug therapies have no proven benefit.

General reference

Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
Professionals also read
Test your knowledge
Acute Cholecystitis
In which of the following patient populations does acalculous cholecystitis tend to follow a febrile illness without an identifiable infecting organism?
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
 

Also of Interest

 
TOP