Hiwa Omer Ahmed Assistant Professor in General Surgery Iraq-Kurdistan Region-University of Sulemani-College of Medicine

ABSTRACT; Background; Gall bladder is a site of different types of diseases starting by infection , stones, functional disorders to cancer of gallbladder. Ultrasonography and CT scan will help in diagnosis of most of these disorders , but functional disorder which is not rare needs special studies for diagnosis like cholecystokinincholescintigraphy with calculation of a gallbladder ejection fraction (GBEF) , gallbladder manometry, and oral cholecystography will help in dynamic study of gallbladder for limited extend, also they need special contrast, gamma camera or radiography with their known side effects. Three dimensional dynamic ultrsonography has no side effects and available , will help in the diagnosis of functional disorders of gallbladder. Aims; In this paper we evaluated the role of three dimensional dyamic ultrasonography in diagnosis of gallbladder dysfuctions Methods; This is prospective study conducted between 1st June 2000 till 31st June 2005 in Sulemani Teaching Hospital, Hatwan Hospital for Endoscopic Surgery and private clinics. Including 186 patients presented with right hypochondrial and or epigastric pain, with history of biliary colic. In 2 groups of patients group A have features of gallbladder dysfunction , group B have no features , underwent three dimensional ultrasound for gallbladder and common bile duct after a fatty meal, we compared gallbladder respond as changes in the size o gall bladder, I 15 ,30 minutes after the meal Results; three dimensional dynamic ultrasound able to diagnose most of the gall bladder dysfunctions as there is significant difference in respond to fatty meal between diseases and abnormal gallbladders Conclusion: We found this method easy, cheap, tolerable, rapid, cost-effective and excellent in diagnosis of gallbladder dysfunctions

Keywords; Three dimential ultrasound, dyskinesia, dysfunction of gallbladder

INTRODUCTION; The gallbladder is pear-shaped, 7.5-12cm long sac, with normal capacity of about 50 ml, but capable of considerable distension in certain pathological conditions (1). It is located in inferiomedial surface of the liver, connected to biliary tree by cystic duct & acts as a reservoir for bile .During fasting resistance to flow of bile through the sphincter of Oddi is high and bile excreted by the liver directed to the gallbladder . After feeding as a reflex arc, with the secretion of cholecystokinin from duodenal mucosa; the resistance to flow via the sphincter decreases, meanwhile the gallbladder contracts and the bile enters the duodenum. With any defect in this reflex arc (duodenal mucosa, CCK, gallbladder or sphincter of Oddi), the gallbladder fails to contract, not secrets bile into duodenum, but distends and produces a group of clinical features called dysfunction of gallbladder Although histology of the gallbladder wall is grossly normal, the muscle cells are functionally abnormal, with an impaired response to agonists that act on membrane and cytosolic receptors ( 2).Symptoms are intolerance to greasy or deep fried foods, bloating, diarrhea, cramping as well as chronic shoulder pain.(3). ). Reduced emptying, which defines gall bladder dysfunction, can arise from depressed gall bladder contraction (4). Acalculous biliary-type abdominal pain is a commonly encountered clinical problem whose pathophysiology is unclear and evaluation and management are controversial.(5) Ultrasound and other imaging are useful in detection of gallbladder stones , thickness of the wall, but dose not help in diagnosis of functional abnormalities of gallbladder. Although oral cholecystography, cholecystokinin-cholescintigraphy with calculation of a gallbladder ejection fraction (GBEF), 1 taurine , beet, liquid iodine, gallbladder manometry sincalide (6) may be helpful in detection of gallbladder dysfunction , but the first needs good patient cooperation, normal gastrointestinal tract & liver function , and the last group needs gamma camera , both may be precluded by possibility of hypersensitivity to these materials. In the present work we tried to evaluate the role of fatty meal as stimulant to the contraction of gallbladder, monitoring changes in the size of gallbladder and thickness of its wall after fat intake. We found this functional ultrasonography is easy, cheap, informative, and acceptable, for large extent by the patients and could be done in outpatient clinic.

PATIENT, MATERIALS and METHODES; This is prospective study conducted between 1st June 2000 till 31st June 2005 in Sulemani Teaching Hospital, Hatwan Hospital for Endoscopic Surgery and private clinics.Including 186 patients presented with right hypochondrial and or epigastric pain , with history of biliary colic. Questioners regarding age, sex, residency, occupation, range of physical activity, type of preferred foods , family history of gallbladder diseases, consumption of fruits , vegetables, coffee and tea done Detailed information about weight loss attempts, age at onset of obesity, parity, presence of menopause, use of contraceptive or hormonal replacement therapy, and phase of menstrual cycle was obtained. Smoking habits, alcohol use, dietary intake, and physical activity were recorded. Blood samples were taken for lipids, glucose,. Mean (SD) fasting gallbladder volume was 18 ml (12.6). The mean residual volume was 15.5 ml after a test meal by 15,30min. and Demographic data recorded. All investigated for liver profile, ultrasound of upper abdomen, all patients were underwent upper gastrointestinal endoscopies. When laboratory, ultrasonography and endoscopy exclude the presence of gall stones, peptic ulcer and other structural abnormalities , we labeled the patient as to has dysfunction of gallbladder when fulfilling the following criteria shown in table I. Because of shortage of oral cholecystography contrast media capsules and absence cholecystokinincholescintography , no patients underwent these functional imaging. Our method of evaluation; After fasting ultrasonography , we gave 100gm of fat in the form of plant butter for 386 patients in tow different groups . Group A have features of gallbladder dysfunction and group B have no features of gallbladder dysfunction according to a criteria as shown in table 1.

Episodes of severe steady pain located in the epigastrium and right upper quadrant, and all of the following: (1) Episodes last 30 minutes or more; (2) Symptoms have occurred on one or more occasions in the previous 12 months; (3) The pain is steady and interrupts daily activities or requires consultation with a physician; (4) There is no evidence of structural abnormalities to explain the symptoms; and (5) There is abnormal gall bladder functioning with regard to emptying. Table I ; Diagnostic criteria of gallbladder dysfunction

Fifteen and 30 minutes later we have repeated the ultrasound of liver , gallbladder and biliry tree, we record gallbladder size, its wall thickness and diameter of CBD (common bile duct ). When there is decrease in the size of gallbladder less than 1/3 of its original size (20), no increase in thickness of the wall of gallbladder and no increase in diameter of CBD, we labeled them as to have dysfunction of gallbladder or nonfunctioning gallbladder. Forty patients underwent laparoscopic cholecystectomy, which isconsidered to be the first line therapy for this dyskinesia (7)andall patients followed up posoperatively for tow years ,all did well early and at the end of the follow-up period regarding their gallbladder features.

RESULTS; Most of the patients were female M/F ratio was ½ as shown in table II

Table II; showing sex distribution in both A & B groups Patients Group A 186 Group B 200 female 119 139 male 63 61

Ninety percent of them were between 35 to 50 years of age as shown in figure I

inciedence in different age group
100 80 60 40 20 0
20 -2 25 5 -3 30 0 -3 35 5 -4 0 40 -4 45 5 -5 50 0 -5 55 5 -6 0

N . o p tie ts o f a n


Figure I; showing age distribution of the patients

With different risk factors for gallbladder stones and dysfunction table III Risk factors Group A No. Tea Consumption Coffee Consumption Fruit & Vegetable Consumption daily (8) Exercise(9,10) Heavy work Family History of Gallbladder disease (11) (12),( 13) History of Enteric Fever Gender; Female Recent weight loss diet programs (14) Hemolytic anemia (15) Any Drugs for Cardiac problems 183 3 70 10 2 75 110 119 % % 98.38 1.61 37.63 5.37 1.07 40.32 59.13 63.97 Group B No. 170 4 81 8 3 18 30 132 % % 85 2 40.5 4 1.5 9 15 66





Table III; Showing Different risk factors in both group Our patients presented with a wide spectra of features, table IV Features Chronic right shoulder pain Bloating Chronic dyspepsia Intolerance to greasy or deep fried foods Diarrhea Epigastric and or right hypochondrial pain lasting for 30 minutes after meals Group A 60 95 60 170 20 70 % 32.25 51.07 32.25 91.39 10.75 37.63 Group B 3 8 2 _ _ % 1.5 0 4 1 0 0 P value 0.0049 0,0049 0.0000 0,0000 0.0000 0.0000

Table IV ; showing features in diagnostic criteria in our work , with P value is less than 0.01 there are significant differences between the samples at the 99% confidence level. Which means that this criteria could be considered as clinical criteria for suspicion of gallbladder dysfunction.

Investigations showed no structural abnormalities table V;

Investigations Liver profile Ultrasound Upper GIT endoscopy

Normal 186 185 181

Finding nil 1 case of Gallstone 4 Gastritis A, 1 Reflux esophagitis

P value 0.9627 0.9627 0,8344

Table V; Showing Investigation results

Details of ultrasonographic finding in both groups table VI;

Ultrasound results

Group A 19 50 7 0 0 65 0 60 56 15 0


Group % B 0 0 0 0 200 200 0 0 0 0 200 0 0 0 0 100 100 0 0 0 0 100

P value

No change in gallbladder size No change in gallbladder wall thickness Enlarged gallbladder Decreased gallbladder wall thickness Decreased gallbladder size by more than 1/3 Increased gallbladder wall thickness Change in the diameter of CBD Decreased gallbladder size Less than 1/5 1/5-1/4 ¼-1/3 more than 1/3

10.21 26.88 3.8 0 0 35 0 32.25 30,10 8.06 0

0.0000 0.0000 0,0000 0.0000 0.0000

0.0000 0.0000 0.0000 0.0000

Table VI; showing ultrasound finding in both groups As long as P value is less than 0.01, all the ultrasound finding considered to have significant in diagnosis of gallbladder dysfunction ( dyskinesia).

Following are ultrasound pictures of two different patients first in group A , with no significant changes in thickness of the wall and size of gallbladder, while second from group B showing significant decrease in size & increase in wall thickness of the gallbladder after fatty meals Groups Group A Before fatty meal postprandial

2.Group B

The size of gallbladder before fatty meal was ranging from (63x19x21mm) = 13 cm3 to (87x38x29mm)= 23 cm3, postprandial in group A at 15 and 30 minutes it changed to (58x18x16mm)=8cm3 to ( 86x28x28mm)= 23cm3. While the thickness of the wall of gallbladder; was ranging from (2mm to 4mm) before fatty meal, postprandial ranging between (2.5 to 5 mm). No dilatation of common bile duct seen postprandial it ranged from (4 to 10 mm).

DISCUSSION; Gallbladder dysfunction is one of the medical problems which is under estimated, on assumption that there is no stones or biliary structural abnormality. But it is not so rare and causes a wide range of features which simulating other gastrointestinal dysfunctions i.e. irritable bowel syndrome. cholecystokinin-cholescintigraphy with calculation of a gallbladder ejection fraction (GBEF) , gallbladder manometry ( 16) , CCK3 quantitative cholescintigraphy (17) , ultrasonography following a medium-chain triglyceride (lipomul, 1.5 mg/kg) infusion into the duodenum(18 ), dynamic sorbite echography of the gallbladder (19),and oral cholecystography will help in dynamic study of gallbladder for limited extend (20,21 ), also they need special contrast, gamma camera or radiography with their known side effects. In this paper we tried to evaluate the role of fatty meal in dynamic study of gallbladder. We found in functioning gallbladders (group B), there is a response as contraction , reduction in size of gallbladder by more than 1/3 of its pre fatty meal size and thickening of its wall in less than 15 minutes. But in nonfunctioning gallbladder (group A) ther were no such changes in 15 and 30 minutes postprandial.the mean residual volum of gallbladder before fatty meal was ( 18 ml ) while postprandially in nonfunctiong gallbladders became ( 15.5 ml ).indicating reduction in gallbladder contractile ratio compared with controls, This indicates that fatty meal could be used as stimulant( 22,23), and provocative agent in dynamic study of gallbladder, on which the option of the treatment depends to do cholecystectomy or not ( 24), there are other foods like chocolate used for dynamic study of gallbladder, but failed to be informative ( 25) We found also fatty meal will provoke the pain , epigastric fullness, bloating and shoulder pain in 73,70, 54 and 30% of the patients in (group A) respectively, which interpreted as additional evidence in diagnoses of dysfunction of gallbladder We found also enteric fever, particularly typhoid fever, is endemic disease; which may cause cholecystitis and decreases both Ca++ release and Ca++ influx in gallbladder smooth muscle or it may cause unresponsiveness to CCK, impairing gallbladder contractility.(26,27) We could say that this functional ultrasonography is easy, cheap, informative, and acceptable, for large extent by the patients and could be done in outpatient clinic.

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