Diagnosis of biliary dyskinesias

Diagnosis of biliary dyskinesia in children is difficult; a comprehensive examination is necessary.

The following methods are used to diagnose biliary dyskinesia.

• Clinical.
• Laboratory.
• Instrumental:
  • ultrasound cholegraphy;
  • radiocontrast cholegraphy;
  • duodenal intubation;
  • radioisotope, including hepatobiliary scintigraphy.

Ultrasound methods are the most significant in diagnosing biliary dyskinesia in children. They allow one to evaluate the shape, size of the gallbladder, the duration of its contraction, the efficiency of bile secretion and the state of the sphincter of Oddi when introducing bile secretion stimulants. During cholecystography (both ultrasound and radiocontrast), the shape, position and emptying of the gallbladder change depending on the type of dyskinesia.

In the hypertensive form, a well-contrasted reduced bladder is detected, its emptying is accelerated. In the hypotonic form, the gallbladder is enlarged, emptying is slow even after repeated administration of stimulants. The results of ultrasound and X-ray studies confirm the presence of functional changes in the biliary system, allow to exclude developmental anomalies, cholelithiasis and the inflammatory process. For assessing the tone and motor function of the biliary system, duodenal sounding is less informative, since the introduction of a metal olive into the duodenum is itself a powerful irritant and cannot reflect the true functional state of the biliary tract. However, a laboratory study of portions of the obtained contents is useful, especially if an inflammatory process is suspected.

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Ultrasound examination

Advantages:

• non-invasive;
• safety;
• high specificity (99%);
• no need for special preparation of the subject;
• fast results.

Indications for the study:

• abdominal syndrome;
• jaundice;
• palpable mass in the upper abdomen;
• hepatosplenomegaly.

Ultrasound signs of biliary system diseases

Echographic sign	Interpretation
Enlarged gallbladder	Hypomotor dyskinesia, "stagnant" gallbladder
Gallbladder reduction	Contracted gallbladder, hypoplasia
Thickening of the gallbladder walls (layering, compaction)	Acute cholecystitis, active chronic cholecystitis
Deformation of the gallbladder walls	Congenital anomaly, pericholecystitis
Gallbladder wall-associated focal lesions	Tumor, cholestasis
Mobile focal formations of the gallbladder	Gallbladder stones
Focal fixed formations of the gallbladder with ultrasound track	"Impacted" concrement
Dilation of the common bile duct	Dyskinesia of the bile ducts, other diseases
Biliary sediment in the cavity of the gallbladder	"Congestive" gallbladder, hypomotor dyskinesia, empyema of the gallbladder
Diagnostic tests with sorbitol, magnesium sulfate, xylitol, egg yolks to assess gallbladder motility	A more intense contraction indicates hypermotility, a weak contraction indicates hypomotility (normally, the volume of the gallbladder should decrease by 50% after 45 minutes).

X-ray examinations

These are leading studies in the diagnosis of diseases of the gallbladder and bile ducts.

In pediatric practice, two methods have become widely used:

1. excretory intravenous cholecysto- and cholecystocholangiography;
2. excretory oral cholecysto- and cholecystocholangiography.

The methods are based on the liver's ability to secrete certain radiopaque substances introduced into the body and concentrate them in the gallbladder. Radiopaque substances can be injected into a vein or taken orally. When taken orally, the contrast is absorbed in the intestine, then through the portal vein system it enters the liver, is secreted by hepatocytes into the bile and enters the gallbladder. With intravenous cholegraphy, the contrast directly enters the bloodstream, reaches the liver cells and is secreted with bile.

Advantages of X-ray methods

Oral cholegraphy:

• the method is physiological;
• allows to study the morphology and functions of the biliary system (motor and concentration functions, gallbladder extensibility).

Intravenous cholegraphy:

• easy to perform and does not require special training;
• reduces diagnostic time;
• provides a more contrasting image of the biliary system.

Contraindications to cholegraphy:

• parenchymal liver diseases; hyperthyroidism;
• heart defects in the decompensation phase;
• nephritis;
• hypersensitivity to iodine;
• acute cholangitis; jaundice.

Transhepatic cholangiography is used for mechanical jaundice. A transabdominal puncture of the dilated intrahepatic duct is performed, a water-soluble contrast suspension is introduced under ultrasound or fluoroscopy control, and serial radiography is performed. The method can be used for therapeutic purposes to relieve the biliary system.

Retrograde endoscopic cholangiopancreatography is the most reliable method for examining the pancreatic and bile ducts by combining duodenoscopy and X-ray contrast examination. The method can also be used for therapeutic purposes to perform sphincterotomy with extraction and spontaneous passage of stones (rarely used in children).

Computed tomography is a highly informative advanced X-ray method that allows one to obtain a large number of cross-sections of the organ being examined and to evaluate its size, shape and structure.

Radionuclide cholescintigraphy is a diagnostic method based on the weakening of the scintigraphic image of the gallbladder as a result of the absorption of a radioactive substance by liver cells. The kinetics of the radiopharmaceutical (RP) allows the following diagnostic tasks to be solved:

• assessment of the anatomical and functional state of the liver and portal blood flow;
• assessment of the anatomical and functional state of the biliary system;
• assessment of the state of the reticuloendothelial system of the liver.

In children, this method is used for abdominal pain syndrome and hepatomegaly, when intravenous cholegraphy cannot be performed due to intolerance to iodine-containing drugs.

Thermal imaging is based on recording infrared radiation from the patient's body surface in black and white or color images using electron-optical scanning. The method is harmless, non-invasive, has no contraindications, and is easy to use.

Laparoscopic diagnostics is used in cases where it is necessary to obtain information about the condition of the gallbladder and its vascularization, to identify effusion in the abdominal cavity, signs of pericholecystitis and damage to the liver parenchyma.

Magnetic resonance imaging cholangiography (MRI cholangiography) allows us to assess the condition of the gallbladder and bile ducts.

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Duodenal intubation

Duodenal sounding has been criticized in recent years due to its impact on the emotional sphere of the child. However, microscopic, bacteriological and biochemical examination of bile allows for a more accurate determination of the nature of changes in the biliary system and an assessment of the predisposition to cholelithiasis. With duodenal sounding, it is also possible to assess the motility of the biliary tract. The study is conducted in the morning on an empty stomach. After inserting the probe, the patient lies on the left side, and gastric contents are aspirated. Then, as the probe is advanced, the patient is placed on the right side. Sounding is performed fractionally.

• The first phase is the phase of the common bile duct. A portion of bile is obtained from the moment of insertion of the probe until the introduction of the stimulator (portion A). In 10-20 minutes, 15-20 ml of yellow bile is secreted. This is a mixture of duodenal contents and pancreatic secretion.
• The second phase is the phase of the closed sphincter of Oddi. This is the period of time from the moment of introduction of the choleretic stimulant until the appearance of the next portion of bile. As a stimulant, 25-30 ml of 33% magnesium sulfate solution (0.5-1.0 ml/kg) is used. The duration of the phase is 3~6 min.
• The third phase is the cystic duct phase. In 3-5 minutes, 3-5 ml of discharge is obtained.
• The fourth phase is the gallbladder phase. Within 15-25 minutes, bile is released from the gallbladder (portion B) in the amount of 30-50 ml.
• The fifth phase is hepatic. Bile is secreted from the liver ducts (portion C) of light yellow color.

The results of bile collection are then analyzed: the dynamics of bile secretion and the rate of bile inflow in each phase of probing are determined. The amount of cholesterol crystals, calcium bilirubinate, the presence of leukocytes, epithelium, and parasites are determined using microscopic examination. Bile portions are sown on special media. In case of microbial flora growth, its sensitivity to antimicrobial drugs is determined. In bile portions B and C, biochemical examination determines the concentration of total cholesterol, free bile acids and their conjugates, bilirubin, sialic acids, C-reactive protein, total protein, lysozyme, lipids, and enzyme activity (lactate dehydrogenase, alkaline phosphatase, creatine kinase, etc.). Changes in these indicators are of great diagnostic importance. An increase in the concentration of total bilirubin and cholesterol indicates cholestasis; an increase in cholesterol with a simultaneous decrease in bile acids - on the violation of the colloidal stability of bile. When the concentration capacity of the gallbladder is violated, the lipoprotein complex of bile decreases. An increase in the concentration of total protein in bile indicates an inflammatory process in the biliary system. The crystallography method is based on the ability of a number of substances to disrupt crystallization centers under inflammatory conditions with the appearance of branched crystals (the assessment is carried out in portions of bile B and C).

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Algorithm for determining the nature of biliary tract motility disorders

Option 1.

During duodenal intubation the following is assessed:

1. nature of motor skills;
2. sphincter tone.

If the results of duodenal sounding do not provide a clear answer about the nature of motility, an ultrasound of the gallbladder with a functional test is performed. •

Option 2.

1. Ultrasound, oral cholecystography:
2. evaluate the motility of the gallbladder;
3. The state of sphincter tone remains unknown.

If stimulation of the gallbladder and its hypermotility are accompanied by the appearance of pain, relieved by antispasmodics, one can assume hypertension of the sphincters.

Slow emptying of the gallbladder may occur:

1. with its hypokinesia in combination with normal or decreased tone of the sphincters;
2. with normal motility or hyperkinesia in combination with increased sphincter tone (manifested by pain relieved by an antispasmodic).

Accelerated emptying of the gallbladder is possible:

1. with hyperkinesia in combination with normal or decreased sphincter tone;
2. with hyperkinesia in combination with increased sphincter tone (manifested by pain relieved by an antispasmodic).

In case of dysfunctional disorders of the biliary tract, there are no changes in the general and biochemical blood tests.

Secondary gallbladder dysfunctions are observed in the following conditions:

1. somatostatinoma and somatostatin therapy;
2. a strict long-term diet for diseases of the stomach and duodenum (gastritis, peptic ulcer), leading to the development of a “lazy” gallbladder;
3. dystrophy or atrophy of the mucous membrane of the duodenum (atrophic duodenitis), leading to a decrease in the synthesis of cholecystokinin;
4. sedentary lifestyle, obesity, irregular meals, long intervals between meals;
5. systemic diseases - diabetes, liver cirrhosis, celiac disease, myotonia, dystrophy;
6. inflammatory diseases of the gallbladder and stones in its cavity;
7. high concentration of estrogens in the blood serum (in the second phase of the menstrual cycle);
8. postoperative conditions.

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