What Is Biliary Dyskinesia?

This disease is more common in women, and its clinical manifestations are very similar to gallbladder stones, mainly manifested as abdominal pain, paroxysmal colic of the upper abdomen or right upper abdomen, and some patients may be associated with nausea and vomiting, which may be induced by eating greasy food, often lasting 2 3h, symptoms relieved after taking antispasmodic drugs.

Biliary dysfunction

Biliary tract dysfunction (biliary tract dyskinesis syndrome) includes biliary tract dysfunction (dyskinesis (ie, abnormal biliary emptying speed)), biliary dysfunction (dystonia (ie, abnormal biliary muscle tone), and ataxic (ataxic) Barriers to coordination). The structure and function of the biliary system are relatively complicated. In recent years, with the continuous improvement of endoscopic techniques and the application of direct pressure measurement technology, it has provided more evidence for the diagnosis of dysfunction of the biliary system.

Biliary motor dysfunction symptoms and signs

1. Pain The core symptom of biliary disease is pain. Pain can originate from the dilated common bile duct, but the pain is often located in the upper abdomen and the right quarter ribs, or in the lower sternum, interscapular area, or even below the back. Pain has nothing to do with diet, but it can also occur after a meal. The pain may also be caused by Oddi sphincter spasm, which is similar in nature and location to biliary colic, but the duration of the attack is short, only a few minutes to half an hour, the number of attacks is frequent, and the day is multiple; the attacks and mental factors such as worry, Nervousness, emotional instability, etc .; Inhalation of isoamyl nitrite or sublingual nitroglycerin 0.6mg during the attack can quickly stop pain; subcutaneous injection of morphine 10mg can induce pain; no fever or jaundice occurs during the attack. Upper right abdominal pain caused by esophagus, small intestine, large intestine or heart disease can also be mistaken for biliary pain. Except for the presence of acute inflammation, the signs are of little help in judging biliary motor disorders.

2. Indigestion symptoms include loss of appetite, belching, feeling of fullness in the upper abdomen, and other symptoms of upper abdominal discomfort.

3. Greasy food Shows reduced tolerance to fatty foods. Some patients cannot tolerate fried foods or high-fat diets, and may experience symptoms such as diarrhea and abdominal pain.

4. Signs Tenderness in the upper abdomen or right upper abdomen, Murphy sign can be positive. It is generally believed to be associated with increased pressure in the bile ducts and inflammation of the bile ducts.

Biliary motor dysfunction medication

Non-surgical treatment

(1) General treatment: adjust life rules to ensure regular meal times, feel peaceful and happy during meals, chew food slowly, take a nap after lunch, adequate sleep, regular physical exercise, and reduce or avoid mood swings. For patients with hyperbiliary motor function and increased tonicity, it is advisable to reduce the fat content in food; for patients with impaired motor function and decreased tonicity, the fat content may be moderate, but if high-fat food can reduce symptoms, it can also be eaten. Treatment should be individualized.

(2) Drug treatment: Mild patients can use sedatives and anticholinergic drugs, such as diazepam (diazepam), atropine, anisodamine (654-2), etc. may work; amyl nitrite and nitroglycerin are also available It relaxes the role of smooth muscle, so it can alleviate sphincter spasm and play a role, but it can have systemic adverse reactions, and drug resistance can occur after long-term use, and it cannot function; glucagon, cholecystokinin, and bombesin, although Both may be effective, but because of their high cost, inconvenience to use, and possible allergic reactions, their widespread use has been limited; calcium antagonists such as nifedipine (arrhythine) can also be used to relieve sphincter spasm.

Patients with pain, chronic noncalculus cholecystitis, and possible infections should use antibiotics that can play a role in bile, such as rifampicin; have duodenitis, hypergastric acid, or peptic ulcer coexist with biliary dyskinesia Patients can be treated with drugs that inhibit gastric acid secretion and protect the gastroduodenal mucosa. For those with gastric acid deficiency, 0.5% dilute hydrochloric acid can be added orally to stimulate appetite.

(3) Oddi sphincter balloon or sac dilatation: Some patients were diagnosed with Oddi sphincter motor dysfunction by performing balloon dilation (Gruntzig balloon) and false expansion. All patients had normal Oddi sphincter basal pressure and the results were effective between the two groups. No significant difference. However, because the diagnosis of these patients has not been determined, and no dilatation study has been performed on those with increased basal pressure, the current conclusion can only say that balloon dilatation may not be effective for those with normal sphincter basal pressure. Because of the unreasonable classification and control of sac dilatation, its efficacy cannot be concluded.

(4) Sphincterotomy: Shortly after endoscopic sphincterotomy was applied to biliary stone removal, this technique began to be used to treat biliary pain caused by sphincteric dyskinesia. 90% of patients with sphincter basal pressure over 40mmHg All of the above can achieve good therapeutic effects. In patients with a basal pressure of less than 40mmHg, the pain relief rate is less than 40%, and the remission rate in simulated operators is about 30%. However, there are very few reports that the basal pressure has nothing to do with the effect. . Most reported incisions have some complications, with an incidence of about 16%, so this procedure should be performed after careful consideration. In general, sphincterotomy has a better effect on the Oddi sphincter resting pressure than 40mmHg, especially for patients with the so-called gallbladder postoperative syndrome, and it has a lower effect on normal resting pressure. Due to the higher complication rate and poor curative effect of pancreatic duct sphincterotomy, most scholars believe that it is not appropriate.

2. Surgical treatment Most patients have different degrees of clinical symptoms after the aforementioned general treatment and drug treatment. If the patient cannot be relieved after conservative treatment, and the endoscopic sphincterotomy is not suitable, surgical treatment should be considered.

Patients with pain due to hypertensive gallbladder, if conservative treatment is not effective, often suggest that non-calculus cholecystitis has developed to the stage of fibrosis of the gallbladder wall. At this time, cholecystectomy should be performed; those with hypotonic gallbladder who have failed drug therapy Some people have reported that the effect is better after removal of the right splanchnic nerve; laparotomy can be performed in patients with compression symptoms or biliary stricture, and whether to perform sphincterotomy according to the specific conditions during the operation. The curative effect and the incidence of complications are similar to those of endoscopic sphincterotomy.

In short, the treatment of biliary dysfunction should first consider conservative treatment, and should actively exclude biliary dysfunction caused by other lesions. After conservative treatment is ineffective and the pros and cons are carefully weighed, invasive treatment can be used.

Biliary dysfunction

What is good for biliary dyskinesia?

Prognosis: Although the diagnosis of biliary motor dysfunction is complicated or difficult and the course is relatively long, the prognosis is mostly good.

health care:

1. Minimize the consumption of fat, especially animal fat, do not eat fatty meat, fried food, and replace animal oil with vegetable oil as much as possible.

2. A considerable part of the formation of cholecystitis and cholelithiasis is indeed related to the high cholesterol content and metabolic disorders in the body. Therefore, it is necessary to limit the roe, the egg yolks of various eggs, and the liver, kidney, heart, and brain of various carnivores Foods high in cholesterol.

3. Steamed, boiled, stewed, and braised food is preferred for cooking. Do not eat fried, fried, roasted, smoked, and pickled food in large quantities.

4. Increase the consumption of foods rich in high-quality protein and carbohydrates such as fish, lean meat, soy products, fresh vegetables and fruits to ensure the supply of calories, thereby promoting the formation of liver glycogen and protecting the liver.

5. Eat tomatoes, corn, carrots and other foods rich in vitamin A to maintain the integrity of gallbladder epithelial cells and prevent epithelial cells from falling off to form the core of the stones, thereby inducing stones, or increasing or increasing the stones.

6. If conditions permit, you can usually drink fresh vegetables or melon juice, such as watermelon juice, orange juice, carrot juice, etc., and increase the frequency and quantity of drinking and eating to increase the secretion and excretion of bile, reduce inflammation and bile Silting.

7. Eat less foods rich in cellulose, such as rutabaga and celery, so as to avoid gastrointestinal peristalsis due to difficulty in digestion, which can cause biliary colic.

8. Quit smoking and drinking, and eat spicy spicy food, strong seasonings, such as mustard oil, so as not to stimulate the gastrointestinal tract and induce or aggravate the disease.

9. It should be light, easy to digest, less dregs, suitable temperature, non-irritating, low-fat liquid or semi-liquid diet. Don't try to "get your hands and feet" out of the air for a while, eat and drink to avoid unnecessary Trouble and even life-threatening biliary tract bleeding.

Preventive care of biliary dyskinesia

Treatment and prevention of diseases related to biliary motor dysfunction.

Pathological causes of biliary dyskinesia

1. Enhanced gallbladder motor function? This type of dysfunction is generally associated with gallbladder allergic reactions or gallbladder inflammation.

(1) Hyperfunction of gallbladder motor: The gallbladder has normal tension but hyperkinetic response to the fat meal, so the gallbladder emptying is accelerated, and it is mostly empty at 15 minutes after the meal.

(2) Gallbladder tension is too high: The muscle tension of the gallbladder is too high, but the emptying time is not affected, and it can be normal, accelerated or delayed.

2. Reduced gallbladder motor function

(1) Gallbladder motor dysfunction: Gallbladder tension is normal, but postprandial contraction is weakened, and emptying is slow.

(2) Decrease in gallbladder tension and motor function: Gallbladder tension decreases when fasting, volume increases, and emptying after meals is slow.

3.Oddi sphincter dysfunction

(1) Oddi sphincter tone is too low: gallbladder filling is poor during cholecystography.

(2) Oddi sphincter spasm: mostly caused by mental factors, but also secondary to lesions in adjacent organs, such as papillitis, duodenitis, bulbous ulcers, duodenal parasites such as intestinal Giardia Roundworm-like infections.

Diagnosis of biliary dyskinesia

1. Lower bile duct stones need to be distinguished from nipple sphincter spasm and organic lesions involving the common bile duct. It can be identified by duodenoscopy retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiopancreatography (PTC).

2. Gallstone (tube) stones can cause gallbladder dilation, which needs to be distinguished from hypertonic gallbladder and hypokinetic gallbladder. Imaging diagnosis (B-ultrasound, CT, and MRI) can detect gallbladder (tube) stones and confirm the diagnosis.

3. Inflammation and infection around the ampulla of the uterus. Its performance can be similar to that of the increased sphincter tone of Oddi, but it can be confirmed by endoscopy.

4. Tumors around the ampulla and pancreatic head can be distinguished from Oddi's increased sphincter tone by B-ultrasound, endoscopy, PTC and other imaging examinations and surgical exploration.

5. Chronic pancreatitis The clinical manifestations may be similar to biliary motor dysfunction, but the former can have a large number of fat droplets and undigested muscle fibers in the stool. Multiple imaging examinations can reveal changes in the shape of the pancreatic ducts and pancreas.

6. Atypical angina pectoris and myocardial infarction The clinical manifestations may be similar to biliary motor dysfunction, but the electrocardiogram and / or myocardial enzymes can detect the corresponding changes in heart disease.

Biliary motor dysfunction examination method

Laboratory inspection:

Liver function and pancreatic enzyme examination: Abdominal pain, alkaline phosphatase and aminotransferase were significantly increased, and no abnormality was found in cholangiography, suggesting that there may be Oddi sphincter dysfunction. However, the clinical situation is not all that typical. Mild impairment of liver function is neither specific nor sensitive. Even after the application of morphine and neostigmine, the typical pain and impairment of liver function and the increase of pancreatic enzymes are typical. High is often inconsistent.

Other auxiliary checks:

Imaging examination

(1) Cholecystography: In the fasting state, the shape and volume of the gallbladder and the rate of gallbladder emptying after a fat meal can reflect the comprehensive effect of various factors controlling bile flow, thus providing a basis for determining whether the biliary system is functioning normally . The gallbladder volume can be calculated by imaging the gallbladder under certain conditions. After 2 to 3 days on a low-fat diet, 6 pantothenic acid tablets were taken, and gallbladder spots were taken on an empty stomach 14 hours later. The patient took the image immediately and developed the image, and then took the left anterior oblique film at a distance of 50cm and 100cm from the film; after that, 3 egg yolks were stirred into 200ml whole milk, and one spoonful of sugar was added and taken orally (Boyden test Meal), 15 minutes after the meal and 60 minutes after the right side of the tablet. Use a transparent paper to trace the gallbladder shadow, and then place it on paper with special lines. The gallbladder shadow is divided into many segments. Measure the diameter of each segment and refer to the table to find the corresponding volume. The sum of the volume of each segment is the total volume. . To eliminate errors, a correction factor (correction factor) can be calculated.

In the fasting state, the normal gallbladder is mostly pear-shaped, and a few are spherical, with an average volume of 32ml ± 5ml, a volume of 16ml ± 3ml at 15min after a fat meal, and 8ml ± 2.5ml at 60min. Based on this, it is determined that the tension when the volume is 32ml ± 5ml, pear-shaped or spherical is normal tension, and at the same time it is determined that the gallbladder volume decreases by 50% and 75% at 15min and 60min after a fat meal, respectively, indicating that the gallbladder contraction and motor function are normal .

The shape and volume of the gallbladder when fasting depends on: the amount of bile secreted by the liver; the pressure of bile secretion from the liver; the permeability of the hepatic duct, the gallbladder duct, and the common bile duct; the internal bile duct pressure; the resistance of the Oddi sphincter; Dilatability; the ability of the gallbladder to condense.

The rate of gallbladder emptying after a fat meal depends on: the formation of a sufficient amount of cholecystokinin; the absorption and transport of cholecystokinin by the blood stream; the ability of the gallbladder muscle to contract; the viscosity of the bile; the permeability of the bile ducts; the Oddi sphincter Relaxation.

(2) Retrograde cholangiopancreatography: Retrograde cholangiopancreatography is the best method to show the secretion of bile and pancreatic juice. It can determine whether there are mechanical or organic changes, but it is of little value in confirming motor dysfunction. Oddi sphincter dysfunction is not easy to detect through this test. Some people have proposed that taking the prone position after retrograde cholangiopancreatography, the delay of the contrast medium outflow time (more than 45min) can be used as a test method to determine the bile emptying disorder. However, due to factors such as the amount of contrast agent injected and medication before the test, etc. Disturbance, so it has not been unified, and its value needs to be further explored.

(3) Nuclide scanning: Nuclide scanning is a more useful method to confirm partial obstruction of the common bile duct. The patient was injected with radionuclide (99mTc) 4 hours after fasting and recorded for 90 minutes. The examination revealed a delay in emptying. The sensitivity and specificity for confirming partial obstruction of the common bile duct were about 67% and 85%, respectively. In contrast to normal people, common bile duct obstruction can cause dilatation of the common bile duct after a fat meal or intravenous injection of cholecystokinin (CCK). If dynamic nuclide scanning detects a delay in common bile duct emptying, it is of value to prove partial obstruction of the common bile duct. Recently, it has been found that it is important to calculate the percentage of gallbladder emptying after CCK injection, especially the reproducibility of emptying ratio is better at 45min. However, radionuclide scanning also has its disadvantages, that is, delayed radionuclide discharge can also occur in the late stage of substantial liver disease. At the same time, its high cost and gamma-ray irradiation are also its disadvantages.

(4) Ultrasound examination: Ultrasound examination showed that the diameter of common bile duct does not change after normal people enter a fat meal or intravenous injection of octapeptide cholecystokinin, but in patients with Oddi sphincter dysfunction, the diameter can increase by 2mm or more (1mm (Diameter change belongs to the measurement error tolerance range). This test can be performed in patients with or without gallbladder or liver disease, and is relatively safe and inexpensive. In addition to the disadvantages, human factors have a greater impact, and the technical and subjective factors of the inspection operator can affect the inspection results. It has been reported that its sensitivity and specificity are 67% and 100%, respectively, but few case studies have confirmed it. Nonetheless, it is expected to serve as an important screening test because it is less invasive and painful and less expensive. It is worth mentioning that common bile duct dilatation is seen in 3% to 4% of asymptomatic patients after cholecystectomy.

2. Manometry Manometry can check the activity of Oddi sphincter. In the past, indirect manometry, that is, during and after surgery, these methods are non-physiological and therefore cannot show rapid changes in sphincter pressure. In 1975, some scholars began to use the direct pressure measurement method, that is, a catheter with a hole at the end was inserted through the endoscope, and it was gradually improved to a three-cavity, three-hole catheter, which can measure three pressures at the same time, each 2mm apart. The basis of direct pressure measurement is that Oddi's sphincter contraction can generate a pressure corresponding to its contraction in the pressure measurement system, which is converted into an electrical signal by an external converter, which is recorded after expansion. At present, endoscopic manometry is considered the gold standard for evaluating Oddi sphincter function. Diazepam should be used before the test. Avoid using anticholinergic drugs, anesthetics, glucagon and other drugs that can affect the function of the sphincter. After inserting the three-lumen cannula, first measure the duodenal pressure and calibrate it to zero. Under the endoscope, the catheter is extended into the nipple. Note that the cannula can move flexibly within the scope of the sphincter to avoid forming sharp bends. The placement of the cannula in the common bile duct can be confirmed by injecting contrast or aspirating bile. Slowly withdraw the cannula and place the three holes in the ampulla sphincter area. Measure the pressure again for 5-10 minutes and record, including the basal pressure and contraction wave. After the catheter exits the nipple, measure the duodenal pressure again. Can also be used to monitor duodenal pressure. After accurate recording of the basal pressure and contraction wave, drugs should be given to further determine the sphincter response. If the basal pressure is significantly increased (more than 40mmHg), inhibitory drugs should be given to distinguish non-fixedness such as increased pressure caused by fixed lesions or convulsions. Caused by the lesion. However, it must be emphasized that such a distinction cannot be made. With the data of basal pressure, systolic wave, and rapid passage, inhalation of isoamyl nitrite (1 ampoule) or nitroglycerin under the tongue. If the basal pressure and intermittent systolic wave are reduced or disappeared, the Possibly; if there is no change or pressure increase, it may indicate the existence of fixed stenosis. Both drugs have a systemic response at the above doses, but isoamyl nitrite is superior because of its shorter duration of action. See Table 2 for Oddi sphincter pressure and systolic measurement criteria.

Although Oddi manometry is technically difficult, it is reproducible. There may also be some artifacts in the tracing, which are mainly caused by frequent sphincter peristalsis, catheter displacement, air bubbles in the manometer system, or leaks in the catheter. Before performing this operation, the anatomical structure needs to be clarified by ERCP, and it is necessary to perform pressure measurement, and it is necessary to confirm whether the contrast agent is flowing out of the pancreatic duct before the pressure measurement. The operation of manometry is relatively safe. After the use of a modified suction catheter, the risk of pancreatitis is greatly reduced, and the manometry can be continued for a long time.

3. Timing of bile drainage Use magnesium sulfate or olive oil as a stimulant, and record the time and amount of bile outflow during each period. In the case that the gallbladder can function normally, the sphincter has a "closed period", also known as the incubation period, which can last 2 to 12 minutes. B bile should appear 8 minutes after the occurrence of A bile. If the time does not match this, there may be a biliary system Dysfunction exists.

Complications of biliary dyskinesia

This disease may appear complications such as diarrhea and abdominal pain.

Prognosis of biliary motor dysfunction

Although the diagnosis of biliary tract dysfunction is complicated or difficult and the course is relatively long, the prognosis is mostly good.

Pathogenesis of biliary dyskinesia

1. The basis of biliary system movement? The anatomical structure of the bile duct system inside and outside the liver is as follows: bile duct Herring duct interlobular bile duct liver duct common hepatic duct gallbladder gallbladder duct common bile duct pancreas duct duodenum, The biliary system receives bile secreted by the liver and performs storage, concentration, and transportation functions, and at the same time can regulate the speed of bile entering the upper small intestine. This process can be affected by many factors in vivo and in vitro, and can lead to motor dysfunction of the biliary system.

The Oddi sphincter consists of three parts, the common bile duct sphincter, the pancreaticobiliary sphincter, and the ampulla sphincter. The ampulla sphincter is a circular muscle, and the other two parts have both circular and oblique muscles. The smooth muscle of the gallbladder wall is divided into two layers: the inner longitudinal longitudinal outer ring; there are some smooth muscles in the common hepatic duct and gallbladder duct, but much less than in the common bile duct and gallbladder, and there is no consensus on their role in bile flow; The submucosa of the duodenum forms the ampulla of the bile and pancreas, about 2 to 17 mm. It opens through the nipple in the descending duodenum. A small number of people do not merge with the common bile duct, but open in the duodenum.

The bile flow of the extrahepatic biliary tract conforms to the principle of fluid mechanics. The pressure is equal to the velocity multiplied by the resistance. Therefore, when the pressure is relatively fixed, the increase in resistance decreases the flow velocity. Resistance in the biliary system is largely related to Oddi sphincter tone. The sphincter pressure exceeds 10 to 30 mmHg of the biliary tract, and the pressure can reach 100 mmHg in 2 to 8 contractions / min. Some of the aforementioned distal biliary system structures generate a certain amount of pressure and determine that bile flows from the bile duct into the duodenum or gallbladder, or is temporarily stored in the biliary tract. Stones and the damage they cause, as well as other injuries, can also affect whether bile enters the gallbladder.

2. Factors affecting the movement function of the biliary system? The movement of the biliary system is affected by a variety of factors in and outside the body. Under normal circumstances, bile flow in the extrahepatic biliary tract can be affected by the following intrinsic factors:

(1) Pressure of liver bile secretion, pressure in bile duct.

(2) The amount of liver bile.

(3) the degree of biliary closure.

(4) Gallbladder wall elasticity, gallbladder muscle tension and contractile function.

(5) Gallbladder concentrating function and bile viscosity.

(6) Tension and responsiveness of the sphincter of the bile duct.

(7) Tension and movement of the duodenal wall.

(8) Closure of duodenal papilla.

(9) The effect of gastrointestinal motility and other parts of the gastrointestinal tract on the biliary system.

(10) The amount of cholecystokinin release, transport efficiency, and inactivation rate.

Among the complex and interrelated factors mentioned above, some are particularly important. Including: bile secretion pressure and Oddi sphincter resistance are important factors determining biliary function. The gallbladder regulates the pressure of the extrahepatic biliary tract, and its shape and volume change with the pressure in the bile duct tree. The gallbladder accepts thin bile into it slowly, and concentrates and stores it. After the normal gallbladder is stimulated by a fat meal, etc., the concentrated bile can be discharged in half within 15 minutes. After pressing the gallbladder area gently and continuously with your hand, the gallbladder can be emptied, but it should not be pressed suddenly. The common bile duct can be dilated to some extent after the functional gallbladder is removed. The amplitude, duration, and frequency of gastrointestinal peristaltic impulse are also closely related to biliary duct pressure and bile flow. However, after the peristaltic impulse exceeds a certain value, increasing frequency or prolonged duration may not promote bile flow, and even May slow it down.

Many hormones and peptides have an effect on Oddi sphincter. Among them, the effect of cholecystokinin on sphincter has been studied extensively. It can shrink the gallbladder and reduce the tension and contraction of Oddi sphincter, including pancreatic duct sphincter. Secretin does not have a significant effect on the biliary sphincter, but it has an inhibitory effect on the pancreatic duct sphincter, while it has an inhibitory effect on the biliary sphincter only at the dose of the drug. In addition, hormones and peptides studied in animal experiments include gastrin, pentagastrin, histamine, and prostaglandin E1. Both histamine and prostaglandin E1 reduce the contractile activity of the sphincter. Prostaglandin E2, motilin, and bombesin have similar effects. Serotonin and endorphin have different effects on different parts of Oddi sphincter.

Study on the effects of some drugs on the sphincter. Butyl anisodamine can block sphincter contractile activity and reduce basal pressure; sublingual nitroglycerin can reduce basal pressure and contraction amplitude without reducing frequency; morphine increases both contraction frequency and basal pressure; Penta Zoxin (analgesic new) only increases basal pressure, but buprenorphine (tert-butorphine) has no effect on the sphincter; pethidine can reduce the frequency of contraction; stabilization has no effect on basal pressure and systolic activity; for Oddi For patients with sphincter dyskinesia, nifedipine (Xintongding) can reduce various activities of the sphincter, but it does not have such effects on normal people; local infusion of bile ducts can significantly increase basal pressure, but ethanol enters the body through the stomach and veins The effects are different. The above results and the effects of some other drugs are shown in Table 1.