Acalculous biliary pain: new concepts for an old entity

Area of Science:

• Gastroenterology
• Hepatobiliary Medicine
• Diagnostic Imaging

Background:

• Biliary pain is frequently attributed to gallstones, but diagnosis is complicated when stones are absent.
• Trans-abdominal ultrasound has limitations for detecting small gallstones (microlithiasis).
• Acalculous gallbladder disease presents a diagnostic challenge without clear pathological findings.

Purpose of the Study:

• To explore advanced diagnostic methods for biliary pain when gallstones are absent.
• To define acalculous gallbladder disease and associated conditions.
• To review the role of surgery and identify challenges in managing functional biliary pain.

Main Methods:

• Endoscopic ultrasound for detecting microlithiasis (< 3 mm).
• Duodenal aspiration of bile to identify cholesterol microlithiasis or bilirubin granules.
• Assessment of cholecystokinin-stimulated gallbladder emptying and biliary manometry.
• Evaluation of visceral hypersensitivity and duodenal hyperalgesia.

Main Results:

• Endoscopic ultrasound and duodenal bile analysis offer improved detection of microlithiasis and acalculous disease.
• Gallbladder emptying abnormalities can stem from gallbladder muscle defects or sphincter of Oddi dysfunction.
• Sphincter of Oddi dysfunction can occur with or without gallstones and may manifest post-cholecystectomy.
• Visceral hypersensitivity, particularly duodenal hyperalgesia, may contribute to functional biliary pain in some patients.

Conclusions:

• Acalculous gallbladder disease and functional biliary pain are distinct clinical entities requiring specialized diagnostic approaches.
• Improved criteria for gallbladder emptying tests and methods for detecting visceral hypersensitivity are needed.
• Management of functional biliary pain remains a clinical challenge, necessitating a comprehensive diagnostic strategy beyond simple gallstone detection.