THE ROLE OF THREE DIMENTIONAL DYNAMIC ULTRASONOGRAPHY IN DIAGNOSIS OF

DYSFUNCTION OF GALLBLLADER

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 cholecystokinin-
cholescintigraphy 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 cholecystokinin-
cholescintography , 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.

DIAGNOSTIC CRITERIA
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 female male

Group A 186 119 63
Group B 200 139 61
Ninety percent of them were between 35 to 50 years of age as shown in figure I

inciedence in different age group

100
No. of patients

80
60
40
20
0
25 5

30 0

35 5
0

45 5

50 0

55 5
0
-2

-3

-3

-4

-4

-5

-5

-6
20

40

age

Figure I; showing age distribution of the patients

With different risk factors for gallbladder stones and dysfunction table III

Risk factors Group A % Group B %

No. % No. %
Tea Consumption 183 98.38 170 85

Coffee Consumption 3 1.61 4 2

Fruit & Vegetable Consumption 70 37.63 81 40.5

daily (8)
Exercise(9,10) 10 5.37 8 4

Heavy work 2 1.07 3 1.5

Family History of Gallbladder 75 40.32 18 9

disease (11) (12),( 13)
History of Enteric Fever 110 59.13 30 15

Gender; Female 119 63.97 132 66

Recent weight loss diet programs
(14)
Hemolytic anemia (15)
Any Drugs for Cardiac problems 2 1.07 3 1.5

Table III; Showing Different risk factors in both group

Our patients presented with a wide spectra of features, table IV

Features Group A % Group B % P value

Chronic right shoulder pain 60 32.25 3 1.5 0.0049
Bloating 95 51.07 - 0 0,0049
Chronic dyspepsia 60 32.25 8 4 0.0000
Intolerance to greasy or deep fried 170 91.39 2 1 0,0000
foods
Diarrhea 20 10.75 _ 0 0.0000
Epigastric and or right hypochondrial 70 37.63 _ 0 0.0000
pain lasting for 30 minutes after
meals

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 Normal Finding P value

Liver profile 186 nil 0.9627

Ultrasound 185 1 case of Gallstone 0.9627
Upper GIT endoscopy 181 4 Gastritis A, 0,8344
1 Reflux esophagitis

Table V; Showing Investigation results

Details of ultrasonographic finding in both groups table VI;

Ultrasound results Group % Group % P value

A B

No change in gallbladder size 19 10.21 0 0 0.0000

No change in gallbladder wall thickness 50 26.88 0 0 0.0000
Enlarged gallbladder 7 3.8 0 0 0,0000
Decreased gallbladder wall thickness 0 0 0 0
Decreased gallbladder size by more than 1/3 0 0 200 100 0.0000
Increased gallbladder wall thickness 65 35 200 100 0.0000
Change in the diameter of CBD 0 0 0 0

Decreased gallbladder size

Less than 1/5 60 32.25 0 0 0.0000
1/5-1/4 56 30,10 0 0 0.0000
¼-1/3 15 8.06 0 0 0.0000
more than 1/3 0 0 200 100 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 Before fatty meal postprandial

Group A

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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