The Decision to Operate in Functional Gall Bladder Disease: Pain as a Critical Factor

Abstract

Background: Pain arising from the gall bladder (GB) or biliary tract in the absence of structural disease seems to be an uncommon clinical condition. It constitutes three varieties of disorders of the biliary tract, namely GB hypokinesia. Gallbladder (GB) pain is commonly caused by gallstone disease, but some patients have functional pain of GB origin and are labelled as functional gallbladder disease (FGBD). Treatment of this disease is not widely standardised. Aim: To evaluate the need for cholecystectomy in subjects with FGBD. This paper aims to investigate functional gall bladder disease, where pain is the critical factor for decision-making.                                                                                                                                                                                                                                                                                                                                                                                                                      Material & Methods: Subjects with RUQ pain and a negative workup (absence of gallstones and ulcer disease) were evaluated for FGBD. Diagnosis was based on GBEF <45% by scintigraphy. It is a retrospective analysis done during the period Jan 2020 to June 2023.  5 mCi of Tc-99 Mebrofenin was administered intravenously, and sequential images were acquired with dual-head gamma camera. A fatty meal was given, and post-meal static images were acquired 1 hour later, and GBEF was calculated. Surgery was carried out in patients with severe symptoms; those with minor symptoms followed up. Results: 116 patients with suspected FGBD were evaluated by HIDA scan. 69/116 had low GBEF, and 47/116 had GBEF >45. Out of 69 patients with low GBEF, data were obtained in 52. Severe symptoms were noted in 20, and 32 had milder symptoms. Those with severe symptoms at presentation or within 4 weeks were subjected to laparoscopic cholecystectomy, and subjects with milder symptoms were followed up. Subjects who underwent surgery (19/20) had significant relief from symptoms, whereas 30/32 with mild symptoms had an uneventful course. A statistically significant difference was found in the ejection fraction between operated and non-operated patients, where the p-value is 0.0142, which the comparison of the Ejection Fraction. Cholecystectomy was carried out in the low GBEF group only if they suffered moderate to severe pain. Patients with milder pains (Pain scale) were asked to follow up, and surgery was not carried out. This approach was based on our earlier experience of finding satisfactory response responses in patients with significant abdominal pain who underwent cholecystectomy. Conclusion: FGBD patients with severe symptoms benefit from cholecystectomy; those with milder pain may be managed symptomatically, thereby avoiding surgery. Presence of severe pain appeares appears to be the predictive indicator of successful outcome in patients with low GBEF.