Diagnosis of biliary dyskinesia

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

For the diagnosis of biliary dyskinesia, the following methods are used.

• Clinical.
• Laboratory.
• Instrumental:
  • ultrasonic choleography;
  • radiopaque choleography;
  • duodenal sounding;
  • radioisotope, including hepatobiliary scintigraphy.

The most significant in the diagnosis of dyskinesia biliary tract in children ultrasound methods. They allow you to assess the shape, size of the gallbladder, the duration of its contraction, the effectiveness of bile secretion and the state of the sphincter of Oddi with the introduction of stimulants of bile secretion. With cholecystography (both ultrasound and radiopaque), the shape, position and emptying of the gallbladder vary depending on the type of dyskinesia.

In hypertensive form, a well-contrasted reduced bladder is detected, its emptying is accelerated. With hypotonic form, the gallbladder is enlarged, the emptying is slowed even after repeated injections of stimulants. The results of ultrasound and X-ray studies confirm the presence of functional changes in the bile excretory system, allow to exclude developmental anomalies, cholelithiasis and inflammatory process. To assess the tone and motor function of the biliary system, duodenal sounding is less informative, since the introduction of the metal olive into the duodenum is in itself a potent stimulus and can not reflect the true functional state of the bile ducts. However, a laboratory study of portions of the obtained contents is useful, especially if there is a suspicion of an inflammatory process.

[1]

Ultrasonography

Benefits:

• non-invasiveness;
• security;
• high specificity (99%);
• absence of the need for special preparation of the subject;
• quick results.

Indications for the study:

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

Ultrasonic signs of diseases of the biliary system

Echographic sign	Treatments
Increased gallbladder	Hypomotor dyskinesia, a "stagnant" gallbladder
Reduction of the gallbladder	Reduced gall bladder, hypoplasia
Thickening of the walls of the gallbladder (lamination, compaction)	Acute cholecystitis, active chronic cholecystitis
Deformation of gallbladder walls	Congenital anomaly, pericholecystitis
Focal gallbladder formations associated with the wall	Tumor, cholestasis
Movable focal formations of the gallbladder	Stones of the gallbladder
Focal stationary formations of the gallbladder with an ultrasound path	"Embossed" stone
Expansion of the common bile duct	Dyskinesia of bile ducts, other diseases
Biliary deposit in the gallbladder cavity	"Congestive" gallbladder, hypomotor dyskinesia, empyema of the gallbladder
Diagnostic tests with sorbitol, magnesium sulfate, xylitol, egg yolks for evaluation of gallbladder motility	A more intensive reduction testifies to hypermotorics, a slight reduction - about hypomotorics (normally the volume of the gall bladder should decrease by 50% in 45 min)

X-ray studies

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

In pediatric practice, two methods were widely used:

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

The methods are based on the ability of the liver to excrete some of the radiopaque substances introduced into the body and concentrate them in the gallbladder. Radiopaque substances can be injected into a vein or applied orally. In case of ingestion, the contrast is absorbed in the intestine, then it penetrates the liver through the portal vein system, is released by the hepatocytes into the bile and enters the gallbladder. With intravenous choleography, the contrast directly enters the bloodstream, reaches the liver cells and is secreted with bile.

Advantages of X-ray methods

Oral choleography:

• the method is physiological;
• allows you to study the morphology and functions of the bile excretory system (motor and concentration functions, the dilatability of the gallbladder).

Intravenous cholegraphy:

• is easy to implement and does not require special training;
• shortens the time of diagnosis;
• gives a more contrast image of the biliary system.

Contraindications to choledography:

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

Transhepatic cholangiography is used for mechanical jaundice. Conduct abdominal puncture of the dilated intrahepatic duct, under the supervision of ultrasound or fluoroscopy, a water-soluble contrast suspension is introduced, serially performing radiography. The method can be used for medicinal purposes to discharge the bile excretory system.

Retrograde endoscopic cholangiopancreatography is the most reliable method that allows to study pancreatic and bile ducts by combining duodenoscopy and radiopaque studies. The method can also be used for a therapeutic purpose for sphincterotomy with extraction and spontaneous passage of stones (in children it is rarely used).

Computed tomography is a highly informative advanced X-ray method that allows to obtain a large number of transverse sections of the organ under study and to estimate 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 radioactive substance being absorbed by the liver cells. Features of the kinetics of radiopharmaceutical (RFP) allow solving the following diagnostic problems:

• evaluation of the anatomical and functional state of the liver and portal blood flow;
• evaluation of the anatomical and functional state of the bile excretory system;
• assessment of the condition of the reticuloendothelial system of the liver.

In children, this method is used for abdominal pain syndrome and hepatomegaly, with the inability to perform intravenous cholegraphy due to intolerance to iodine-containing drugs.

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

Laparoscopic diagnosis is used in those cases when it is necessary to obtain information about the state of the gallbladder and its vascularization, to reveal effusion in the abdominal cavity, signs of pericholecystitis and lesions of the liver parenchyma.

Magnetic resonance tomography cholangiography (MRI-cholangiography) allows to assess the state of the gallbladder and bile ducts.

[2], [3], [4], [5], [6]

Duodenal sounding

Duodenal sounding in recent years has been criticized because of its influence on the emotional sphere of the child. Nevertheless, microscopic, bacteriological and biochemical examination of bile allows to more accurately determine the nature of changes in the biliary system, assess the predisposition to cholelithiasis. With duodenal sounding, it is also possible to evaluate the motility of the bile ducts. The study is carried out in the morning on an empty stomach. After the introduction of the probe, the examinee lies on the left side, and aspirates the gastric contents. Then the patient is placed on the right side while moving the probe. The sounding is carried out fractionally.

• The first phase is the phase of the common bile duct. A portion of bile is obtained from the moment the probe is inserted before the stimulant is introduced (portion A). For 10-20 minutes, 15-20 ml of yellow bile is secreted. It is a mixture of duodenal contents and pancreatic secretions.
• The second phase is the phase of the closed sphincter of Oddi. This is the period of time from the time the choleretic stimulant is introduced until the next bile appears. As a stimulant, 25-30 ml of a 33% solution of magnesium sulfate (0.5-1.0 ml / kg) is used. The duration of the phase is 3 ~ 6 min.
• The third phase is the phase of the cystic duct. For 3-5 minutes, 3-5 ml of the extractable material is obtained.
• The fourth phase is bubbly. Within 15-25 minutes bile out of the gallbladder (portion B) is released in an amount of 30-50 ml.
• The fifth phase is hepatic. Bile from the liver passages (portion C) is light yellow.

Then the results of the bile collection are analyzed: the dynamics of bile secretion, the rate of bile in each phase of sounding are determined. Determination of the number of cholesterol crystals, calcium bilirubinate, the presence of leukocytes, epithelium, parasites is carried out with the help of microscopic examination. Production of bile portions is carried out on special media. In the case of growth of microbial flora determine its sensitivity to antimicrobial drugs. In bile portions B and C, the concentration of total cholesterol, free bile acids and their conjugates, bilirubin, sialic acids, C-reactive protein, total protein, lysozyme, lipids, activity of enzymes (lactate dehydrogenase, alkaline phosphatase, creatine kinase, etc., ). Changes in these indicators are of great diagnostic value. An increase in the concentration of total bilirubin and cholesterol indicates a phenomenon of cholestasis; increase cholesterol while reducing bile acids - on the violation of colloidal resistance bile. When the concentration capacity of the gallbladder is reduced, the bile lipoprotein complex decreases. The inflammation in the biliary system is indicated by an increase in bile concentrations of total protein. The method of crystallography is based on the ability of a number of substances to disrupt crystallization centers in conditions of inflammation with the appearance of branched crystals (the evaluation is carried out in portions of bile B and C).

[7], [8], [9]

Algorithm for determining the nature of biliary tract motility disorders

Option 1.

When duodenal probing is evaluated:

1. the nature of motor skills;
2. tonus of sphincters.

If the results of duodenal sounding do not give an unambiguous 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 the sphincter tone remains unknown.

If stimulation of the gallbladder and its hypermotorics is accompanied by the appearance of pain, which is suppressed by antispasmodics, it is possible to assume hypertension of the sphincters.

Delayed emptying of the gallbladder is possible:

1. at its or his hypokinesia in a combination to normal or reduced tone of sphincters;
2. with normal motor skills or hyperkinesia combined with an increased tone of the sphincters (manifested by pain, spazmolitik).

Accelerated emptying of the gallbladder is possible:

1. at a hyperkinesia in a combination to normal or reduced tone of sphincters;
2. at a hyperkinesia in a combination to the raised or increased tone of sphincters (it is shown by the pain which is coped with spasmolytic).

With dysfunctional disorders of the biliary tract, there is no change in the general and biochemical blood analysis.

Dysfunctions of the gallbladder of a secondary nature are observed under the following conditions:

1. somatostatinoma and somatostatin therapy;
2. a strict long-term diet for diseases of the stomach and duodenum (gastritis, peptic ulcer disease), 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 diet, large intervals between meals;
5. systemic diseases - diabetes, cirrhosis, celiac disease, myotonia, dystrophy;
6. inflammatory diseases of the gallbladder and concrements in its cavity;
7. high concentration of estrogens in the blood serum (during the second phase of the menstrual cycle);
8. postoperative conditions.

[10], [11], [12], [13], [14], [15]