Development and clinical application of new scintigraphic and manometric methods for the diagnosis of functional disorders of the gallbladder and the sphincter of Oddi

To summarize our results, an optimal diagnostic and therapeutic approach may be suggested in patients with functional biliary disorders. It is worth mentioning that the diagnostic strategy should be modified individually in accord with the clinical status of the patient. Consequently, the clinical value and diagnostic role of QHBS must be evaluated in relation to the degree of biliary obstruction. ERCP must be performed in all cases when the obstruction is a high-grade one, when gallstone disease is suspected by the ultrasound, or when AN-augmented QHBS suggests an organic biliary obstruction. If no clinical sign of biliary obstruction is evident in a patient with functional biliary pain, it is reasonable to start with AN-augmented QHBS to determine bile flow abnormalities. After the exclusion of organic causes, the probability of SO dyskinesia or GB dyskinesia is high if a typical clinical picture is accompanied by a suggestive QHBS result. The clinician should then decide whether ESOM is indicated to establish the diagnosis. The latter also depends on the therapeutic plan, since the QHBS results might not be sufficient to plan an operative endoscopic procedure such as EST, which is not without risk. In contrast, if drug therapy is planned, positive scintigraphy should be sufficient for the initiation of medical treatment. It is generally accepted and proved by long-term follow-up studies that in patients with SO stenosis (SOD of biliary group I) EST is the treatment of choice [98-100]. As these patients with SOD of biliary type I invariably benefit from EST, ESOM is not necessary [100]. In contrast, in patients with SO dyskinesia (biliary groups II and III) ESOM is needed to perform in order to prove the elevated SO BP as an indication of EST, since in patients with SO dyskinesia and a normal SO BP EST did not prove to be more beneficial than the sham procedure [101]. Moreover, in another follow-up study, a sustained symptomatic improvement was detected after EST in only 8% of the patients with SOD of biliary type III (functional group) [102]. Therefore, with regard to the high incidence of complications following EST in patients with non-dilated ducts, it should be considered only after a failure of conservative therapy in the subgroup of patients with an elevated SO BP [103]. If all these tests are negative, then a provocation test may be considered, such as a prostigmine-morphine test combined with QHBS. Provocation tests might unmask subtle abnormalities, such as hyperreactivity of the SO, which explain the patient`s complaints. In patients with ABP, and an intact GB with normal SO motility, QHBS combined with CCK and GTN coadministration should be performed to establish the diagnosis of GB dyskinesia. To summarize the present work, we proved that QHBS is a useful method in the diagnosis of functional disorders of the biliary tract. We established a close correlation between the bile flow determined by QHBS and the SO pressure measured by ESOM. We applied AN and prostigmine-morphine augmentations, QHBS thereby becoming a real functional test in the diagnosis of SOD. We combined QHBS with CCK and GTN coadministration in patients with intact GB and ABP, which could be a reliable method in the diagnosis of GB dyskinesia. We hope that, in the future, these methods will gain general acceptance as a first line diagnostic test in patients with suspected biliary dyskinesia.
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