Digestive Diseases and Sciences

, Volume 59, Issue 6, pp 1307–1315 | Cite as

Biliary Dyskinesia and Symptomatic Gallstone Disease in Children: Two Sides of the Same Coin?

  • Arvind I. Srinath
  • Ada O. Youk
  • Klaus Bielefeldt
Original Article



Despite lack of consensus criteria, biliary dyskinesia (BD) is an increasingly accepted pediatric diagnosis.


We compared patient characteristics, outcomes, and resource utilization (before and after surgery) between children with BD and symptomatic cholecystolithiasis (LITH).


Data from the electronic medical record were abstracted for children diagnosed with BD or LITH between December 1, 2002, and November 30, 2012, at Children’s Hospital of Pittsburgh.


Four hundred and ten patients were identified (BD: 213 patients, LITH: 197 patients). Patients with BD had significantly lower BMI, longer symptom duration, more dyspeptic symptoms, and were more likely to present with other symptoms. Forty-one patients (13.8 %) with BD underwent cholecystectomy despite a normal gallbladder ejection fraction (GB-EF). In 32 of these, sincalide triggered pain compared to 75 of the 155 patients with low GB-EF. After surgery, patients with BD more commonly visited gastroenterology clinics and had more GI-related hospitalizations, while emergency room visits decreased in both groups. Only the nature of biliary disease independently predicted continuing pain after surgery, which in turn was the best predictor for higher resource utilization after cholecystectomy.


A large percentage of children with BD did not meet the adult diagnostic standards. Compared to those with LITH, children with BD have more widespread symptoms and continue to use more clinical resources after surgery. These findings suggest that despite its benign prognosis, BD is increasingly treated like other potentially acute gallbladder diseases, although it has the typical phenotype of FGIDs and should be treated using approaches used in such disorders.


Biliary dyskinesia Cholecystolithiasis Cholecystectomy Functional gastrointestinal disorders 



Crohn’s & Colitis Foundation Research Fellowship Award Grant #3590.

Conflict of interest



  1. 1.
    Starfield B, Hoekelman RA, McCormick M, et al. Who provides health care to children and adolescents in the United States? Pediatrics. 1984;74:991–997.PubMedGoogle Scholar
  2. 2.
    Talley N, Stanghellini V, Heading R, Koch K, Malagelada J, Tytgat G. Functional gastroduodenal disorders. Gut. 1999;45:37–42.CrossRefGoogle Scholar
  3. 3.
    Tack J, Talley NJ, Camilleri M, et al. Functional gastroduodenal disorders. Gastroenterology. 2006;130:1466–1479.PubMedCrossRefGoogle Scholar
  4. 4.
    Behar J, Corazziari E, Guelrud M, Hogan W, Sherman S, Toouli J. Functional gallbladder and sphincter of oddi disorders. Gastroenterology. 2006;130:1498–1509.PubMedCrossRefGoogle Scholar
  5. 5.
    Shulman RJ, Eakin MN, Jarrett M, Czyzewski DI, Zeltzer LK. Characteristics of pain and stooling in children with recurrent abdominal pain. J Pediatr Gastroenterol Nutr. 2007;44:203–208.PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Wesdorp I, Bosman D, de Graaff A, Aronson D, van der Blij F, Taminiau J. Clinical presentations and predisposing factors of cholelithiasis and sludge in children. J Pediatr Gastroenterol Nutr. 2000;31:411–417.PubMedCrossRefGoogle Scholar
  7. 7.
    Rasquin A, Di Lorenzo C, Forbes D, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2006;130:1527–1537.PubMedCrossRefGoogle Scholar
  8. 8.
    Bielefeldt K. The rising tide of cholecystectomy for biliary dyskinesia. Aliment Pharmacol Ther. 2013;37:98–106.PubMedCrossRefGoogle Scholar
  9. 9.
    Campbell BT, Narasimhan NP, Golladay ES, Hirschl RB. Biliary dyskinesia: a potentially unrecognized cause of abdominal pain in children. Pediatr Surg Int. 2004;20:579–581.PubMedCrossRefGoogle Scholar
  10. 10.
    Al-Homaidhi HS, Sukerek H, Klein M, Tolia V. Biliary dyskinesia in children. Pediatr Surg Int. 2002;18:357–360.PubMedCrossRefGoogle Scholar
  11. 11.
    Michail S, Preud’Homme D, Christian J, et al. Laparoscopic cholecystectomy: effective treatment for chronic abdominal pain in children with acalculous biliary pain. J Pediatr Surg. 2001;36:1394–1396.PubMedCrossRefGoogle Scholar
  12. 12.
    Scott Nelson R, Kolts R, Park R, Heikenen J. A comparison of cholecystectomy and observation in children with biliary dyskinesia. J Pediatr Surg. 2006;41:1894–1898.PubMedCrossRefGoogle Scholar
  13. 13.
    Yap L, Wycherley AG, Morphett AD, Toouli J. Acalculous biliary pain: cholecystectomy alleviates symptoms in patients with abnormal cholescintigraphy. Gastroenterology. 1991;101:786–793.PubMedGoogle Scholar
  14. 14.
    Lyons H, Hagglund KH, Smadi Y. Outcomes after laparoscopic cholecystectomy in children with biliary dyskinesia. Surg Laparosc Endosc Percutan Tech. 2011;21:175–178.PubMedCrossRefGoogle Scholar
  15. 15.
    Carr JA, Walls J, Bryan LJ, Snider DL. The treatment of gallbladder dyskinesia based upon symptoms: results of a 2-year, prospective, nonrandomized, concurrent cohort study. Surg Laparosc Endosc Percutan Tech. 2009;19:222–226.PubMedCrossRefGoogle Scholar
  16. 16.
    Chumpitazi BP, Malowitz SM, Moore W, Gopalakrishna GS, Shulman RJ. Concomitant gastroparesis negatively affects children with functional gallbladder disease. J Pediatr Gastroenterol Nutr. 2012;54:776–779.PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Gurusamy KS, Junnarkar S, Farouk M, Davidson BR. Cholecystectomy for suspected gallbladder dyskinesia. Cochrane Database Syst Rev. 2009;1:CD007086.Google Scholar
  18. 18.
    Hansel SL, DiBaise JK. Functional gallbladder disorder: gallbladder dyskinesia. Gastroenterol Clin N Am. 2010;39:369–379, x.Google Scholar
  19. 19.
    Haricharan RN, Proklova LV, Aprahamian CJ, et al. Laparoscopic cholecystectomy for biliary dyskinesia in children provides durable symptom relief. J Pediatr Surg. 2008;43:1060–1064.PubMedCrossRefGoogle Scholar
  20. 20.
    Hofeldt M, Richmond B, Huffman K, Nestor J, Maxwell D. Laparoscopic cholecystectomy for treatment of biliary dyskinesia is safe and effective in the pediatric population. Am Surg. 2008;74:1069–1072.PubMedGoogle Scholar
  21. 21.
    Karnsakul W, Vaughan R, Kumar T, Gillespie S, Skitarelic K. Evaluation of gastrointestinal pathology and treatment in children with suspected biliary dyskinesia. Pediatr Surg Int. 2011;27:1307–1312.PubMedCrossRefGoogle Scholar
  22. 22.
    Patel NA, Lamb JJ, Hogle NJ, Fowler DL. Therapeutic efficacy of laparoscopic cholecystectomy in the treatment of biliary dyskinesia. Am J Surg. 2004;187:209–212.PubMedCrossRefGoogle Scholar
  23. 23.
    Ponsky TA, DeSagun R, Brody F. Surgical therapy for biliary dyskinesia: a meta-analysis and review of the literature. J Laparoendosc Adv Surg Tech A. 2005;15:439–442.PubMedCrossRefGoogle Scholar
  24. 24.
    Rastogi A, Slivka A, Moser AJ, Wald A. Controversies concerning pathophysiology and management of acalculous biliary-type abdominal pain. Dig Dis Sci. 2005;50:1391–1401.PubMedCrossRefGoogle Scholar
  25. 25.
    Sabbaghian MS, Rich BS, Rothberger GD, et al. Evaluation of surgical outcomes and gallbladder characteristics in patients with biliary dyskinesia. J Gastroint Surg. 2008;12:1324–1330.CrossRefGoogle Scholar
  26. 26.
    Singhal V, Szeto P, Norman H, Walsh N, Cagir B, Vander Meer TJ. Biliary dyskinesia: how effective is cholecystectomy? J Gastroint Surg. 2012;16:135–140; discussion 140–131.Google Scholar
  27. 27.
    Telega G. Biliary dyskinesia in pediatrics. Curr Gastroenterol Rep. 2006;8:172–176.PubMedCrossRefGoogle Scholar
  28. 28.
    Lacher M, Yannam GR, Muensterer OJ, et al. Laparoscopic cholecystectomy for biliary dyskinesia in children: frequency increasing. J Pediatr Surg. 2013;48:1716–1721.PubMedCrossRefGoogle Scholar
  29. 29.
    Bohman H, Jonsson U, Paaren A, von Knorring L, Olsson G, von Knorring AL. Prognostic significance of functional somatic symptoms in adolescence: a 15-year community-based follow-up study of adolescents with depression compared with healthy peers. BMC Psychiatry. 2012;12:90.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Frank L, Kleinman L, Rentz A, Ciesla G, Kim JJ, Zacker C. Health-related quality of life associated with irritable bowel syndrome: comparison with other chronic diseases. Clin Ther. 2002;24:675–689; discussion 674.Google Scholar
  31. 31.
    Hunfeld JA, Perquin CW, Duivenvoorden HJ, et al. Chronic pain and its impact on quality of life in adolescents and their families. J Pediatr Psychol. 2001;26:145–153.PubMedCrossRefGoogle Scholar
  32. 32.
    Lipani TA, Walker LS. Children’s appraisal and coping with pain: relation to maternal ratings of worry and restriction in family activities. J Pediatr Psychol. 2006;31:667–673.PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Liebman WM. Recurrent abdominal pain in children: a retrospective survey of 119 patients. Clin Pediatr (Phila). 1978;17:149–153.CrossRefGoogle Scholar
  34. 34.
    Garber J, Zeman J, Walker LS. Recurrent abdominal pain in children: psychiatric diagnoses and parental psychopathology. J Am Acad Child Adolesc Psychiatry. 1990;29:648–656.PubMedCrossRefGoogle Scholar
  35. 35.
    Greco LA, Freeman KE, Dufton L. Overt and relational victimization among children with frequent abdominal pain: links to social skills, academic functioning, and health service use. J Pediatr Psychol. 2007;32:319–329.PubMedCrossRefGoogle Scholar
  36. 36.
    Campo JV, Comer DM, Jansen-Mcwilliams L, Gardner W, Kelleher KJ. Recurrent pain, emotional distress, and health service use in childhood. J Pediatr. 2002;141:76–83.PubMedCrossRefGoogle Scholar
  37. 37.
    Crushell E, Rowland M, Doherty M, et al. Importance of parental conceptual model of illness in severe recurrent abdominal pain. Pediatrics. 2003;112:1368–1372.PubMedCrossRefGoogle Scholar
  38. 38.
    Longstreth GF, Yao JF. Irritable bowel syndrome and surgery: a multivariable analysis. Gastroenterology. 2004;126:1665–1673.PubMedCrossRefGoogle Scholar
  39. 39.
  40. 40.
    Morris-Stiff G, Falk G, Kraynak L, Rosenblatt S. The cholecystokin provocation HIDA test: recreation of symptoms is superior to ejection fraction in predicting medium-term outcomes. J Gastrointest Surg. 2011;15:345–349.PubMedCrossRefGoogle Scholar
  41. 41.
    DuCoin C, Faber R, Ilagan M, Ruderman W, Wier D. Normokinetic biliary dyskinesia: a novel diagnosis. Surg Endosc. 2012;26:3088–3093.PubMedCrossRefGoogle Scholar
  42. 42.
    St Peter SD, Keckler SJ, Nair A, et al. Laparoscopic cholecystectomy in the pediatric population. J Laparoendosc Adv Surg Tech A. 2008;18:127–130.PubMedCrossRefGoogle Scholar
  43. 43.
    Siddiqui S, Newbrough S, Alterman D, Anderson A, Kennedy A. Efficacy of laparoscopic cholecystectomy in the pediatric population. J Pediatr Surg. 2008;43:109–113.PubMedCrossRefGoogle Scholar
  44. 44.
    Constantinou C, Sucandy I, Ramenofsky M. Laparoscopic cholecystectomy for biliary dyskinesia in children: report of 100 cases from a single institution. Am Surg. 2008;74:587–592.PubMedGoogle Scholar
  45. 45.
    Misra S. Is biliary scintigraphy a reliable diagnostic tool for biliary dyskinesia in children? J Clin Gastroenterol. 2011;45:814–817.PubMedCrossRefGoogle Scholar
  46. 46.
    Chang FY, Lu CL. Irritable bowel syndrome and migraine: bystanders or partners? J Neurogastroent Motil. 2013;19:301–311.CrossRefGoogle Scholar
  47. 47.
    Wu JC. Community-based study on psychological comorbidity in functional gastrointestinal disorder. J Gastroenterol Hepatol. 2011;26:23–26.PubMedCrossRefGoogle Scholar
  48. 48.
    Kaye AJ, Jatla M, Mattei P, Kelly J, Nance ML. Use of laparoscopic cholecystectomy for biliary dyskinesia in the child. J Pediatr Surg. 2008;43:1057–1059.PubMedCrossRefGoogle Scholar
  49. 49.
    Dumont RC, Caniano DA. Hypokinetic gallbladder disease: a cause of chronic abdominal pain in children and adolescents. J Pediatr Surg. 1999;34:858–861; discussion 861–852.Google Scholar
  50. 50.
    Halata MS, Berezin SH. Biliary dyskinesia in the pediatric patient. Curr Gastroenterol Rep. 2008;10:332–338.PubMedCrossRefGoogle Scholar
  51. 51.
    Vegunta RK. Efficacy of laparoscopic cholecystectomy in the pediatric population. J Pediatr Surg. 2008;43:1418; author reply 1418.Google Scholar
  52. 52.
    Knott EM, Fike FB, Gasior AC, et al. Multi-institutional analysis of long-term symptom resolution after cholecystectomy for biliary dyskinesia in children. Pediatr Surg Int. 2013;29:1243–1247.PubMedCrossRefGoogle Scholar
  53. 53.
    Maxwell D, Thompson S, Richmond B, McCagg J, Ubert A. Quality of life after laparoscopic cholecystectomy for biliary dyskinesia in the pediatric population: a pilot study. Am Surg. 2012;78:111–118.PubMedGoogle Scholar
  54. 54.
    Siddiqui S, Newbrough S, Alterman D, Anderson A, Kennedy A, Jr. Efficacy of laparoscopic cholecystectomy in the pediatric population. J Pediatr Surg. 2008;43:109–113; discussion 113.Google Scholar
  55. 55.
    Delgado-Aros S, Cremonini F, Bredenoord AJ, Camilleri M. Systematic review and meta-analysis: does gall-bladder ejection fraction on cholecystokinin cholescintigraphy predict outcome after cholecystectomy in suspected functional biliary pain? Aliment Pharmacol Ther. 2003;18:167–174.PubMedCrossRefGoogle Scholar
  56. 56.
    Drossman DA, Corazziari E, Delvaux M, et al. Rome III: The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA: Degnon Associates; 2006.Google Scholar
  57. 57.
    Wybourn CA, Kitsis RM, Baker TA, Degner B, Sarker S, Luchette FA. Laparoscopic cholecystectomy for biliary dyskinesia: which patients have long term benefit? Surgery. 2013;154:761–767; discussion 767–768.Google Scholar
  58. 58.
    Cohen MM, Young W, Theriault ME, Hernandez R. Has laparoscopic cholecystectomy changed patterns of practice and patient outcome in Ontario? CMAJ. 1996;154:491–500.PubMedCentralPubMedGoogle Scholar
  59. 59.
    Legorreta AP, Silber JH, Costantino GN, Kobylinski RW, Zatz SL. Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy. JAMA. 1993;270:1429–1432.PubMedCrossRefGoogle Scholar
  60. 60.
    Escarce JJ, Chen W, Schwartz JS. Falling cholecystectomy thresholds since the introduction of laparoscopic cholecystectomy. JAMA. 1995;273:1581–1585.PubMedCrossRefGoogle Scholar
  61. 61.
    Roma E, Kafritsa Y, Panayiotou J, Liakou R, Constantopoulos A. Is peptic ulcer a common cause of upper gastrointestinal symptoms? Eur J Pediatr. 2001;160:497–500.PubMedCrossRefGoogle Scholar
  62. 62.
    Walker SK, Maki AC, Cannon RM, Foley DS, Wilson KM, Galganski LA, et al. Etiology and incidence of pediatric gallbladder disease. Surgery. 2013;154:927–931; discussion 931–923.Google Scholar
  63. 63.
    Herschbach P, Henrich G, von Rad M. Psychological factors in functional gastrointestinal disorders: characteristics of the disorder or of the illness behavior? Psychosom Med. 1999;61:148–153.PubMedCrossRefGoogle Scholar
  64. 64.
    Walker LS, Greene JW. Children with recurrent abdominal pain and their parents: more somatic complaints, anxiety, and depression than other patient families? J Pediatr Psychol. 1989;14:231–243.PubMedCrossRefGoogle Scholar
  65. 65.
    Devanarayana NM, Adhikari C, Pannala W, Rajindrajith S. Prevalence of functional gastrointestinal diseases in a cohort of Sri Lankan adolescents: comparison between Rome II and Rome III criteria. J Trop Pediatr. 2011;57:34–39.PubMedCrossRefGoogle Scholar
  66. 66.
    Dong L, Dingguo L, Xiaoxing X, Hanming L. An epidemiologic study of irritable bowel syndrome in adolescents and children in China: a school-based study. Pediatrics. 2005;116:e393–e396.PubMedCrossRefGoogle Scholar
  67. 67.
    Frissora CL, Koch KL. Symptom overlap and comorbidity of irritable bowel syndrome with other conditions. Curr Gastroenterol Rep. 2005;7:264–271.PubMedCrossRefGoogle Scholar
  68. 68.
    Youssef NN, Murphy TG, Langseder AL, Rosh JR. Quality of life for children with functional abdominal pain: a comparison study of patients’ and parents’ perceptions. Pediatrics. 2006;117:54–59.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Arvind I. Srinath
    • 1
  • Ada O. Youk
    • 2
  • Klaus Bielefeldt
    • 3
  1. 1.Division of Pediatric GastroenterologyChildren’s Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC)PittsburghUSA
  2. 2.Department of BiostatisticsUniversity of PittsburghPittsburghUSA
  3. 3.Division of GastroenterologyUniversity of Pittsburgh Medical Center (UPMC)PittsburghUSA

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