cholecystokinin and Abdominal-Pain

Laparoscopic cholecystectomy is accepted therapy for children with ill-defined abdominal pain and impaired gallbladder emptying (biliary dyskinesia). Follow-up shows poor clinical response in many of these patients. The purpose of this report is to identify clinical and radiographic predictors of successful outcome after cholecystectomy for biliary dyskinesia.. The authors retrospectively reviewed records of 51 children after laparoscopic cholecystectomy for biliary dyskinesia (1990 to 2003). Clinical symptoms, radiographic findings, and pathology were evaluated. Subjective clinical improvement is stratified using an established patient satisfaction score. Logistic regression analysis determines statistically independent predictors of successful outcome.. Thirty-eight of 51 (75%) patients were available for follow-up. Twenty-seven of 38 (71%) patients reported complete resolution of symptoms. Nausea was the only symptom predictive of successful outcome by univariate analysis (odds ratio, 5.00). A cholecystokinin-stimulated, gallbladder ejection fraction less than 15% also predicts successful outcome (odds ratio, 8.00). Children with an ejection fraction greater than 15% did not have predictable resolution of symptoms. When present with pain and nausea, gallbladder emptying less than 15% has a positive predictive value of 93% and a negative predictive value of 81%.. Together, nausea, pain, and decreased gallbladder emptying (<15%) most reliably predict which children will benefit from cholecystectomy for biliary dyskinesia.

Topics: Abdominal Pain; Adolescent; Biliary Dyskinesia; Child; Child, Preschool; Cholecystectomy, Laparoscopic; Cholecystokinin; Cohort Studies; Female; Follow-Up Studies; Gallbladder Emptying; Humans; Infant; Infant, Newborn; Male; Nausea; Predictive Value of Tests; Radiography; Retrospective Studies; Treatment Outcome

The use of cholescintigraphy to diagnose acute cholecystitis, biliary obstruction, and biliary leakage dates back to the late 1970s. Today, despite the many advances in imaging instrumentation, radiopharmaceuticals, and methodology over these years, cholescintigraphy still plays an important role in confirming or excluding these diagnoses in acutely ill patients. Acute calculous and acalculous cholecystitis, gallbladder perforation, biliary obstruction, and biliary leakage often present as acute abdominal pain, and must be differentiated from other surgical and nonsurgical etiologies with similar symptoms and presentation. Understanding the pathophysiology of acute hepatobiliary diseases is vital for deciding on the most advantageous imaging work-up and for interpretation of the studies. To optimize the value of cholescintigraphy, up-to-date methology, proper use of appropriate pharmacologic interventions, and recognition of characteristic image findings are critical.

Topics: Abdominal Pain; Acute Disease; Biliary Fistula; Biliary Tract; Cholecystectomy; Cholecystitis, Acute; Cholecystokinin; Cholestasis; Diagnosis, Differential; False Positive Reactions; Humans; Morphine; Practice Patterns, Physicians'; Radionuclide Imaging; Sensitivity and Specificity

In patients who present with chronic unexplained upper abdominal pain or discomfort (functional dyspepsia), therapy should ideally be targeted on correcting the individual's disturbed pathophysiology. Here, putative mechanisms implicated in functional dyspepsia and potential approaches to therapy are critically reviewed in order to determine if targeting treatment is of value. Pharmacological therapies reviewed include those that aim to correct disordered gastric emptying (e.g. cisapride, dopaminergic receptor antagonists, macrolides), reduce visceral hypersensitivity (e.g. somatostatin analogues, cholecystokinin antagonists, opioid agonists, serotonin type 3 receptor antagonists), reduce gastric acid secretion (e.g. H2-blockers, acid pump inhibitors), cure Helicobacter pylori infection, enhance muscosal defence (e.g. sucralfate, bismuth) or modify central nervous system processes. It is concluded that the imperfectly understood pathophysiology of functional dyspepsia contributes to the paucity of established efficacious therapies.

Topics: Abdominal Pain; Antidepressive Agents; Bismuth; Calcium Channel Blockers; Cholecystokinin; Dyspepsia; Gastric Emptying; Helicobacter Infections; Humans; Narcotics; Nitric Oxide; Prostaglandins, Synthetic

Acalculous biliary pain has been related to gallbladder dysfunction that produces a gallbladder emptying defect-a condition which favours the development of lithiasis. It is therefore probable that microlithiasis is present in patients with gallbladder dysfunction. The aims of this study were to measure gallbladder emptying and investigate bile abnormalities in patients with acalculous biliary pain. In 92 consecutive patients, gallbladder emptying was assessed by quantitative cholescintigraphy (abnormal ejection fraction < or =40%). In 64 patients, a microscopic study was performed on duodenal bile, defining abnormality as the presence of cholesterol crystals in any amount and/or calcium bilirubinate granules and/or microspheroliths at a rate of >10 per slide. The ejection fraction was abnormal in 45 patients (49%) (median 25.1%, range 6.8-39.3%) and normal in the remaining 47 cases (median 71.3%, range 41.0-96.1%). Bile was abnormal in 32 of 64 patients (50%), the most frequent finding being calcium bilirubinate granules. In the patients with bile abnormalities, abnormal ejection fraction was more frequent (20 of 32) and the median ejection fraction was lower (30.9%, range 12.0-94.1%) than in the patients with normal bile (16 of 32 with an abnormal ejection fraction; median ejection fraction 50.7%, range 6.8-96.1%). Abnormal bile was frequent (55.5%) in patients with reduced ejection fraction, but was not uncommon in patients with normal ejection fraction (33.3%). Fewer patients showed no alteration (25%). It is concluded that in most patients, acalculous biliary pain coexists with gallbladder dysfunction or abnormal bile, the combination of both alterations being common.

Topics: Abdominal Pain; Acalculous Cholecystitis; Adult; Bile; Cholecystokinin; Cholelithiasis; Female; Humans; Male; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; Sensitivity and Specificity; Statistics as Topic; Technetium Tc 99m Disofenin

Over 500,000 patients undergo cholecystectomy annually in the United States for symptoms of upper abdominal discomfort and pain ascribed to gallbladder disease. However, approximately 5%, or 25,000 of these cases do not have gallstones on ultrasound examination but typically present with chronic symptoms of biliary colic. These patients often present as challenging diagnostic dilemmas and are often treated as if their symptoms are secondary to peptic ulcer disease or other gastrointestinal-related disorders. In 1992, we began to use the cholecystokinin (CCK) challenge test on patients with normal ultrasound examinations of the gallbladder but who had chronic symptoms resembling biliary colic. The CCK test was considered positive if the identical symptoms of discomfort or pain, usually in the right upper quadrant of the abdomen, were reproduced. This study describes the first 24 patients who had a positive CCK challenge test and chose to undergo cholecystectomy for relief of their symptoms. No patient was lost to follow-up evaluation at 1 to 24 months after operation.

Topics: Abdominal Pain; Adult; Aged; Biliary Tract Diseases; Cholecystectomy; Cholecystitis; Cholecystokinin; Chronic Disease; Colic; Diagnosis, Differential; Female; Follow-Up Studies; Humans; Male; Middle Aged; Pain Measurement

This study was aimed to investigate the effect of long-term treatment with high-protease pancreatic extract on the recurrent abdominal pain of patients with chronic pancreatitis.. Twenty-six patients with a firm diagnosis of chronic pancreatitis and a pattern of recurrent pain were recruited and randomly assigned to treatment with pancreatic extract (Pancrex-Duo capsules, each containing 34,375 USP units of protease in enteric-coated microspheres) or placebo, at a dose of four capsules four times daily, for 4 months. At the end of the first period patients were switched to the other medication for the next 4 months. Four patients did not complete the study because of unbearable recurring pain or inadequate compliance with treatment. The other 22 patients daily recorded the presence, intensity, and duration of pain and the consumption of analgesics, for 8 months.. No difference was found when intraindividual records during placebo and extract treatment periods were compared. Conversely, in the second 4 months of follow-up, regardless of the treatment given in the first period, there was a significant reduction in the cumulative pain score (median, 95; range, 0-1005, versus 134; 0-972; p < 0.05), in the number of days (8; 0-132, versus 13; 0-126; p < 0.02) and hours (54; 0-680, versus 80; 0-602; p < 0.05) of pain, and in the analgesic consumption score (0; 0-22, versus 12; 0-44; p = 0.02).. Chronic supplementation with pancreatic extract is not beneficial in the management of recurrent pain in patients with chronic pancreatitis.

Topics: Abdominal Pain; Adult; Aged; Analysis of Variance; Cholecystokinin; Chronic Disease; Cross-Over Studies; Double-Blind Method; Female; Humans; Male; Middle Aged; Pain Measurement; Pancreatic Extracts; Pancreatitis; Recurrence; Time Factors

Distal colonic motor activity was measured in 12 control subjects and seven constipation-predominant irritable bowel syndrome patients to examine the effects of intravenous administration of cholecystokinin. In the basal state, no significant motility differences were noted between these two groups. Following the intravenous administration of the hormone cholecystokinin, a statistically significant reduction in colonic motility in control subjects and a non-significant decrease in motility in irritable bowel syndrome patients was seen. Our results do not suggest an exaggeration of the colonic motor response to cholecystokinin occurs in irritable bowel syndrome.

Topics: Abdominal Pain; Adult; Cholecystokinin; Colon; Colonic Diseases, Functional; Constipation; Female; Gastrointestinal Motility; Humans; Informed Consent; Injections, Intravenous; Male; Manometry; Sincalide

Cholecystokinin stimulated HIDA (CCK-HIDA) has been used to identify patients with biliary dyskinesia and select patients likely to benefit from cholecystectomy. The appropriate use of this study in children remains controversial and this study aims to better understand the utility of this test.. Children who underwent a CCK-HIDA for evaluation of abdominal pain over a 15-year period were included, after excluding infants and patient's s/p liver transplant. Relevant clinical and outcomes data were abstracted and analyzed.. 124 patients met inclusion criteria. Mean age was 14.5 ± 2.6 years, Mean BMI was 27.9 ± 9.9 and 96 (77.4%) presented with right upper quadrant or epigastric pain. The mean ejection fraction (EF) was 58.5 ± 31.8%, with 37 (29.8%) < 35% EF. Using receiver operating curve analysis no specific EF threshold value predictive of resolution of symptoms was identified (AUC 0.510; p = 0.94). Using EF <35% and >35% and <20% and >20%, no association was noted with partial/complete resolution of symptoms. On multivariate regression analysis neither EF nor pain reproduction with CCK administration were independently associated with resolution of symptoms.. These data suggest that the CCK-HIDA scan is a poor predictor of benefit from cholecystectomy. Prospective large studies would help in identifying better criterion for patient selection, especially with the trend of increasing surgery for functional gallbladder disorders.. Case cohort.. IV.

Topics: Abdominal Pain; Adolescent; Biliary Dyskinesia; Child; Cholecystokinin; Humans; Imino Acids; Prospective Studies; Retrospective Studies

Biliary dyskinesia (BD) is a motility disorder of the gallbladder that can result in right upper quadrant (RUQ) pain, nausea, vomiting, and diarrhea. Cholecystectomy is considered the standard of care for BD. Up to 23 per cent of pediatric patients who undergo surgery for BD have persistent symptoms postoperatively. We performed a retrospective review to identify preoperative factors significantly associated with symptom resolution after cholecystectomy. We retrospectively reviewed pediatric patients aged 10-17 years diagnosed with BD who underwent cholecystectomy between 2006 and 2016. Patients were divided into two groups based on postoperative symptom resolution. Chi-squared and student

Topics: Abdominal Pain; Adolescent; Biliary Dyskinesia; Child; Cholagogues and Choleretics; Cholecystectomy, Laparoscopic; Cholecystokinin; Constipation; Female; Gallbladder; Humans; Male; Nausea; Retrospective Studies; Symptom Assessment; Treatment Outcome

Despite the increasing use of fatty meal (FM) as a substitute for cholecystokinin (CCK) in pain reproduction during hepato-imino-diacetic acid (HIDA) scan in functional gallbladder disorder, there are no studies comparing the differences between CCK and FM. The present study was to compare the efficacy of FM in comparison of CCK in FGBD application.. Patients undergoing HIDA scans from August 2013 to May 2014 were divided into two groups: those undergoing CCK-stimulated HIDA scan versus FM-stimulated HIDA scan. These groups were compared according to demographics and HIDA results.. Of 153 patients, 70 received CCK and 83 FM. There was no difference regarding age, gender, gallstones, gallbladder ejection fraction and time to visualization. However, significantly more of the patients receiving CCK than FM experienced pain reproduction (61% vs 30%, P<0.01).. Stimulation of gallbladder contractility with a FM during HIDA is less than half as likely to reproduce biliary symptoms compared to CCK, despite similar ejection fractions and other parameters. It is essential that providers account for this difference when counseling patients regarding cholecystectomy for functional gallbladder disorder.

Topics: Abdominal Pain; Adolescent; Adult; Aged; Aged, 80 and over; Biliary Dyskinesia; Cholecystectomy; Cholecystokinin; Dietary Fats; Female; Gallbladder; Humans; Imino Acids; Male; Middle Aged; Predictive Value of Tests; Radiopharmaceuticals; Vitamin K; Young Adult

Irritable bowel syndrome is characterized by abdominal pain and altered bowel habits and may occur following stressful events or infectious gastroenteritis such as giardiasis. Recent findings revealed a link between cholecystokinin (CCK), neurotrophin synthesis, and intestinal hyperalgesia. The aim was to investigate the role of CCK in visceral hypersensitivity using mouse models challenged with a bout of infection with Giardia lamblia or psychological stress, either alone or in combination.. Abdominal pain was evaluated by visceromoter response to colorectal distension. Nerve fibers in intestinal tissues were stained using immunohistochemistry (PGP9.5). Human neuroblastoma SH-SY5Y cells incubated with bacterial-free mouse gut supernatant or recombinant CCK-8S were assessed for neurite outgrowth and nerve growth factor (NGF) production.. Intestinal hypersensitivity was induced by either stress or Giardia infection, and a trend of increased pain was seen following dual stimuli. Increased CCK levels and PGP9.5 immunoreactivity were found in colonic mucosa of mice following stress and/or infection. Inhibitors to the CCK-A receptor (L-364718) or CCK-B receptor (L-365260) blocked visceral hypersensitivity caused by stress, but not when induced by giardiasis. Nerve fiber elongation and NGF synthesis were observed in SH-SY5Y cells after incubation with colonic supernatants from mice given the dual stimuli, or after treatment with CCK-8S. Increased nerve fiber length by colonic supernatant and CCK-8S was attenuated by L-365260 or neutralizing anti-NGF.. This new model successfully recapitulates intestinal hypernociception induced by stress or Giardia. Colonic CCK contributes to visceral hypersensitivity caused by stress, but not by Giardia, partly via NGF-dependent neurite outgrowth.

Topics: Abdominal Pain; Animals; Cells, Cultured; Cholecystokinin; Coculture Techniques; Colon; Culture Media, Conditioned; Dilatation; Giardia lamblia; Giardiasis; Humans; Hyperalgesia; Intestinal Mucosa; Male; Mice, Inbred C57BL; Nerve Fibers; Nerve Growth Factor; Neuronal Outgrowth; Recombinant Proteins; Stress, Psychological

Chronic acalculous gallbladder disease (CAGD) falls within the spectrum of diseases associated with gallbladder dysmotility. Cholecystokinin-cholescintigraphy (CCK-CS) has been used to evaluate for CAGD, with a gallbladder ejection fraction (GBEF) of <35 % being indicative of gallbladder dysfunction. The reproduction of biliary colic upon administration of CCK has been cited as indicative of CAGD. Our purpose was to determine whether low GBEF or reproduction of pain during CCK-CS was predictor of surgical outcomes related to resolution of symptoms or as a correlate to gallbladder pathology.. A retrospective review of patients was performed to evaluate adults with a diagnosis of CAGD who underwent CCK-CS prior to surgical intervention. CPT and ICD-9 coding queries were used to identify the patient population. Patients with cholelithiasis were excluded.. Sixty-four patients met inclusion criteria. Two patients were lost to follow-up and were excluded. During CCK-CS, 41 patients (66 %) reported symptoms similar to their presenting complaint. Twenty-one patients reported no symptoms with CCK-CS. There was no significant relationship between gallbladder pathology and either GBEF or reproduction of symptoms with CCK-CS (p = 0.14). About 81 % of patients (n = 50) had relief of symptoms following cholecystectomy. Sixty-six percentage of patients (n = 33) with long-term symptom relief after cholecystectomy had reproduction of symptoms with CCK-CS. Nineteen percentage of all patients (n = 12) had long-term symptom recurrence despite surgery. Eight of these patients (66 %) had symptom reproduction with CCK-CS. There was no significant correlation with either the GBEF or symptoms reproduction with CCK-CS as a predictor of postoperative outcome (p = 0.12).. Provocation of pain by CCK-CS and low GBEF are unreliable predictors of postoperative relief of symptoms following cholecystectomy for biliary dyskinesia or chronic acalculous gallbladder disease.

Topics: Abdominal Pain; Anorexia; Cholecystectomy; Cholecystokinin; Gallbladder; Gallbladder Diseases; Humans; Nausea; Pain Measurement; Radionuclide Imaging; Vomiting

Studies on biliary dyskinesia have been based on short-term surgical follow-up and do not take into consideration that most patients are discharged from surgical follow-up after the first postoperative visit and that for persistent or recurrent symptoms they are frequently seen by primary care providers and subsequently referred to gastroenterologists. We aimed to study this pattern and assess which factors predict patients that will benefit from cholecystectomy.. This is a retrospective analysis of medical records of patients who underwent cholecystectomy for biliary dyskinesia from February 2001 to January 2010 with a minimum postoperative follow-up of 6 months.. At initial surgical follow-up, 19 of 141 (13.4%) patients said they had persistent symptoms. However, when subsequent visits were analyzed, 61 of 141 (43.3%) patients with persistent or recurrent symptoms saw their primary care provider. These symptoms were epigastric or right upper quadrant pain in 43 patients or 30% of those undergoing cholecystectomy. The only factor that distinguished patients with and without resolution of symptoms after cholecystectomy was the pathologic finding of inflammation (p = 0.02).. Cholecystectomy does not appear to be as effective for biliary dyskinesia when long-term follow-up is evaluated.

Topics: Abdominal Pain; Adolescent; Adult; Aged; Biliary Dyskinesia; Child; Cholecystectomy; Cholecystitis; Cholecystokinin; Female; Follow-Up Studies; Gastroenterology; Humans; Male; Middle Aged; Patient Selection; Primary Health Care; Recurrence; Referral and Consultation; Retrospective Studies; Treatment Outcome; Young Adult

It has been suggested that there could be three possible mechanisms of gastric dysfunction in patients with FD: (i) delayed gastric emptying, (ii) impaired gastric accommodation of food intake, and (iii) hypersensitivity to gastric distention. Postprandial fullness seems to be the most severe symptom in patients who report aggravation of their symptoms after meals. Therefore, it has been assumed that delayed gastric emptying and consequent prolonged antral distension could reduce hunger, increase satiety, and even cause gastric discomfort, all of which would pose a significant barrier to adequate nutrition. We previously reported that postprandial water intake inhibits gastric antral motility along with an increase of cholecystokinin (CCK) in normal subjects. We assumed that the rapid increase of CCK after water intake was initiated by a feedback mechanism related to the inflow of fatty chyme into the duodenum that inhibits gastric antral activity. This duodeno-gastric interaction is known as the "duodenal break." We also reported that total gastric emptying was more rapid after the intake of a high-viscosity liquid meal than after a low-viscosity meal, because the low-viscosity liquid meal inhibits gastric emptying after rapid initial inflow into the duodenum. Considering these results, we hypothesized that rapid gastric emptying, rather than delayed gastric emptying, could be a cause of FD. In some patients with postprandial distress syndrome (PDS), we have found a significant correspondence between PDS-related dyspepsia and accelerated gastric emptying in the early postprandial period. It is worth emphasizing that the duodenum and the duodeno-gastric interaction (duodenal break) could have an important role in the pathophysiology of FD. We consider that rapid gastric emptying might be a more important factor than delayed gastric emptying in patients with FD.

Topics: Abdominal Pain; Cholecystokinin; Diet; Drinking; Duodenum; Dyspepsia; Eating; Feedback, Physiological; Gastric Emptying; Humans; Postprandial Period; Viscosity

Coptis chinensis rhizomes (Coptidis Rhizoma, CR), also known as "Huang Lian", is a common component of traditional Chinese herbal formulae used for the relief of abdominal pain and diarrhea. Yet, the action mechanism of CR extract in the treatment of irritable bowel syndrome is unknown. Thus, the aim of our present study is to investigate the effect of CR extract on neonatal maternal separation (NMS)-induced visceral hyperalgesia in rats and its underlying action mechanisms.. Male Sprague-Dawley rats were subjected to 3-h daily maternal separation from postnatal day 2 to day 21 to form the NMS group. The control group consists of unseparated normal (N) rats. From day 60, rats were administrated CR (0.3, 0.8 and 1.3 g/kg) or vehicle (Veh; 0.5% carboxymethylcellulose solution) orally for 7 days for the test and control groups, respectively.. Electromyogram (EMG) signals in response to colonic distension were measured with the NMS rats showing lower pain threshold and increased EMG activity than those of the unseparated (N) rats. CR dose-dependently increased pain threshold response and attenuated EMG activity in the NMS rats. An enzymatic immunoassay study showed that CR treatment significantly reduced the serotonin (5HT) concentration from the distal colon of NMS rats compared to the Veh (control) group. Real-time quantitative PCR and Western-blotting studies showed that CR treatment substantially reduced NMS induced cholecystokinin (CCK) expression compared with the Veh group.. These results suggest that CR extract robustly reduces visceral pain that may be mediated via the mechanism of decreasing 5HT release and CCK expression in the distal colon of rats.

Topics: Abdominal Pain; Analgesics; Animals; Cholecystokinin; Colon; Coptis; Disease Models, Animal; Dose-Response Relationship, Drug; Drugs, Chinese Herbal; Electromyography; Hyperalgesia; Irritable Bowel Syndrome; Male; Maternal Deprivation; Muscle, Smooth; Pain Threshold; Phytotherapy; Rats; Rats, Sprague-Dawley; Rhizome; Serotonin; Stress, Psychological

For children with upper abdominal pain and evaluation for acalculous biliary disease, laparoscopic cholecystectomy is an accepted treatment with inconsistent outcomes. The purpose of this study was to identify predictors of outcomes.. One hundred sixty-seven children underwent laparoscopic cholecystectomy at a single children's hospital. Radiographic findings, histopathology, family history, and demographics (sex, age, height, weight, body mass index-for-age percentile) were evaluated as predictors of postoperative symptomatic resolution using a binomial probability model. The data for radiologic studies and pathologic specimens were obtained via re-review in a blinded fashion.. Of 167 children, 43 (25.7%) had a preoperative diagnosis of biliary dyskinesia and 41 (95.3%) had documented follow-up. Mean follow-up was 8.4 months. Twenty-eight patients (68.3%) had symptom resolution. Ejection fraction less than or equal to 15%, pain upon cholecystokinin injection, and a family history of biliary disease were not predictors of symptomatic resolution. Nonoverweight patients (body mass index-for-age <85th percentile) were more likely to have symptom resolution than their overweight counterparts (odds ratio, 2.13). Most patients (68.3%) had a pathologic gallbladder on blinded review. However, this did not correlate with outcome.. Most gallbladders removed for biliary dyskinesia are pathologic. Being overweight can be considered a relative contraindication to cholecystectomy for biliary dyskinesia.

Topics: Abdominal Pain; Adolescent; Biliary Dyskinesia; Body Mass Index; Child; Cholecystectomy, Laparoscopic; Cholecystitis; Cholecystokinin; Cohort Studies; Colic; Contraindications; Dietary Fats; Female; Gallbladder; Humans; Imino Acids; Male; Overweight; Radiography; Risk Factors; Single-Blind Method; Stroke Volume; Treatment Outcome; Young Adult

The placebo effect has evolved from being considered a nuisance factor in clinical research to a hot topic of scientific investigation. New research findings show that a placebo has real psychobiological and biological effects that are attributable to the overall therapeutic context. Irritable bowel syndrome (IBS) is a functional disorder of the gastrointestinal tract that shows a significant placebo response of around 40–50% among different clinical trials.A positive patient-practitioner relationship can enhance the placebo effect in IBS patients.Emerging literature using functional brain imaging has started to document the neuronal changes associated with the placebo phenomenon in IBS patients, showing aberrant neural network during visceral placebo analgesia when compared to controls. Further promotion and integration of laboratory and clinical research are encouraged to advance the understanding of placebo mechanisms in IBS patients.

Topics: Abdominal Pain; Analgesics; Brain; Cholecystokinin; Clinical Trials as Topic; Colon; Drug Synergism; Gastrointestinal Agents; Humans; Irritable Bowel Syndrome; Magnetic Resonance Imaging; Meta-Analysis as Topic; Placebo Effect; Positron-Emission Tomography; Treatment Outcome

Experience with laparoscopic cholecystectomy for biliary dyskinesia in children remains limited. The aim of this study was to examine the results of a single institution's experience with laparoscopic cholecystectomy for the treatment biliary dyskinesia in the pediatric population. Medical records were reviewed on all patients younger than age 18 who underwent laparoscopic cholecystectomy at our institution from July 2004 to December 2006. Patients undergoing surgery for biliary dyskinesia, as evidenced by a preoperative gallbladder ejection fraction of 40 per cent or less, comprised the study group. Of the 51 pediatric laparoscopic cholecystectomies, 30 (58.8%) were performed for biliary dyskinesia. The patients' ages ranged from 7 to 17 (mean, 12.67 years; SD, 2.75). Symptoms consisted of chronic right upper quadrant pain (96.67%), nausea/vomiting (73.33%), back pain (30.0%), weight loss (13.33%), and a history of pancreatitis (6.66%). The amount of time between onset of symptoms and surgery was as follows: 1 to 3 months (34.62%), 4 to 6 months (30.77%), 7 to 12 months (7.69%), and greater than 1 year (26.92%). Gallbladder ejection fraction ranged from 1 to 36 per cent (mean, 14.7%). Seven of the 30 (26.67%) underwent endoscopic evaluation as part of their preoperative workup (six upper endoscopy, one colonoscopy), all of which were noncontributory. Pathology revealed chronic cholecystitis in 26 of 30 (93.3%), no abnormalities in three of 30 (10.0%), and unexpected cholelithiasis in one of 30 (3.33%). No perioperative complications were encountered. Twenty-nine of the 30 patients were available for follow up and all but one reported relief of symptoms (96.55%). This study supports the use of laparoscopic cholecystectomy as a safe and effective treatment for biliary dyskinesia in the pediatric population. The success rate in our study was substantially higher than that reported in previous series. Routine preoperative endoscopy was not used and was reserved for investigation of ambiguous or unrelated complaints.

Topics: Abdominal Pain; Adolescent; Age Factors; Biliary Dyskinesia; Child; Cholecystectomy, Laparoscopic; Cholecystokinin; Cohort Studies; Endoscopy; Female; Humans; Male; Retrospective Studies; Treatment Outcome

Chronic pancreatitis should be considered in all patients with unexplained abdominal pain. Management of abdominal pain in these patients continues to pose a formidable challenge. The importance of small duct disease without radiographic abnormalities is now a well-established concept. It is meaningful to determine whether patients with chronic pancreatitis have small duct or large duct disease because this distinction has therapeutic implications. Diagnostic evaluation should begin with simple noninvasive and inexpensive tests like serum trypsinogen and fecal elastase, to be followed where appropriate by more complicated measures such as the secretin hormone stimulation test, especially in patients with suspected small duct disease. No universal causal treatment is available. Non-enteric-coated enzyme preparations are useful for treatment of pain, whereas enteric-coated enzyme preparations are preferred for steatorrhea. Octreotide is used increasingly for abdominal pain that is unresponsive to pancreatic enzyme therapy. When medical therapy for chronic pancreatitis pain has failed, endoscopic therapy, endoscopic ultrasound-guided celiac plexus block, and thoracoscopic splanchnicectomy, performed by experts, may be considered for a highly selected patient population. Surgical ductal decompression is appropriate in patients with considerable pancreatic ductal dilation. The role and efficacy of cholecystokinin-receptor antagonists, antioxidants, and antidepressant drugs remain to be defined.

Topics: Abdominal Pain; Cholecystokinin; Chronic Disease; Devazepide; Endosonography; Gastrointestinal Agents; Gastroparesis; Hormone Antagonists; Humans; Octreotide; Pancreatic Function Tests; Pancreatitis

Patients with acalculous biliary-like pain present a difficult clinical challenge. Our aim was to evaluate the outcome of patients with recurrent biliary-like pain without gallstones who underwent testing of gallbladder ejection fraction (GBEF) by cholecystokinin-cholescintigraphy (CCK-CS) in order to determine clinical factors that may predict symptom resolution. We reviewed the records of patients with recurrent acalculous biliary-like pain who underwent CCK-CS from January 1995 to December 1999. For comparison, we also studied an age- and sex-matched group of patients who underwent cholecystectomy for symptomatic cholelithiasis. Outcome was obtained by telephone interview, using a scale from 0 to 3 where 0 = no improvement and 3 = clinical remission. Patient demographics, predominant symptom(s), method of management, gallbladder pathology, and response to treatment were recorded. One hundred twenty-nine patients underwent CCK-CS. Of 69 with an abnormal GBEF, 48 (70%) were available for interview. Forty patients underwent cholecystectomy. Twenty-seven patients reported symptom resolution after surgery while 4 nonsurgical patients reported the same (P = NS). Univariate analysis revealed no association between symptom outcome and presence of gastrointestinal symptom(s), severity and duration of abdominal pain, management, or gallbladder pathology. In addition, no GBEF cutoff level predicted symptom outcome. Of the remaining 60 patients with a normal GBEF, 30 (50%) were available for interview. Twenty-eight patients in this group were managed medically and 2 patients underwent cholecystectomy. Eighteen patients managed medically were asymptomatic, as were the 2 who underwent cholecystectomy. There was no difference in symptom outcome between patients who had GBEF >35% vs <35%. In conclusion, in a group of patients with recurrent acalculous biliary-like pain who underwent CCK-CS, we found a high rate of symptom resolution following cholecystectomy; however, this was not statistically different from a smaller cohort who did not undergo surgery. We were unable to determine any variable predictive of symptom resolution.

Topics: Abdominal Pain; Adult; Analysis of Variance; Biliary Dyskinesia; Cholecystectomy; Cholecystokinin; Cholelithiasis; Cohort Studies; Female; Gallbladder Diseases; Gallbladder Emptying; Humans; Male; Middle Aged; Probability; Prognosis; Radionuclide Imaging; Retrospective Studies; Sensitivity and Specificity; Severity of Illness Index; Technetium Tc 99m Disofenin

Topics: Abdominal Pain; Biliary Tract; Cholecystokinin; Cholestasis, Extrahepatic; Cystic Duct; Gallbladder; Gallbladder Emptying; Humans; Nitroglycerin; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Diethyl-iminodiacetic Acid; Ultrasonography; Vasodilator Agents

Topics: Abdominal Pain; Algorithms; Carrier Proteins; Cholecystokinin; Chronic Disease; Enzyme Therapy; Feedback; Growth Substances; Humans; Intercellular Signaling Peptides and Proteins; Pancreas; Pancreatitis; Trypsin Inhibitor, Kazal Pancreatic

Impaired gallbladder emptying has been identified as a cause of chronic abdominal pain in adults. This study aims to define a pediatric population with functional abnormalities of gallbladder contractility and to assess clinical outcome after cholecystectomy.. Children and adolescents (n = 42) with abdominal complaints underwent gallbladder emptying studies, measured by either ultrasonography or scintigraphy with intravenous cholecystokinin (CCK). On ultrasound studies, gallbladder volume was measured before injection and 15 minutes after injection. Measures of gallbladder emptying by scintigraphy were taken at least 30 minutes after CCK injection. A study was classified as abnormal for contractility less than 50%. Cholecystectomy was performed and outcomes were evaluated during office visits and by telephone interview.. Abdominal pain and fatty food intolerance were the predominant symptoms. Patients were treated by open (n = 2) or laparoscopic (n = 40) cholecystectomy. In 20 cases the gallbladder showed chronic inflammation on pathology. Response to surgical therapy was excellent in 41 patients (mean follow-up, 20.4 months).. Children and adolescents with persistent abdominal pain should undergo functional assessment of gallbladder contractility. Patients with abnormal gallbladder contractility benefit from cholecystectomy.

Topics: Abdominal Pain; Adolescent; Child; Cholecystokinin; Chronic Disease; Female; Gallbladder; Gallbladder Diseases; Gallbladder Emptying; Humans; Male; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Diethyl-iminodiacetic Acid

Topics: Abdominal Pain; Bile Acids and Salts; Cholecystokinin; Chronic Disease; Duodenum; Eating; Humans; Osmolar Concentration; Pain; Pancreatitis; Prospective Studies

Plasma cholecystokinin levels were measured in children with recurrent abdominal pain to investigate the relationship of plasma cholecystokinin levels with colonic transit patterns and clinical symptoms. Subjects consisted of 120 children (mean age 9.6 +/- 2.6 years) for whom colonic transit study had also been done. Plasma cholecystokinin levels were 79.2 +/- 58.7 pg/mL in children with colonic inertia, 70.7 +/- 47.0 pg/mL in hindgut dysfunction, 57.4 +/- 53.1 pg/mL in pelvic outlet obstruction, and 67.6 +/- 47.9 pg/mL in normal colonic transit. These data showed that there was a tendency of increasing plasma cholecystokinin levels in children with proximal colon transit delay, although there was no significant difference among four groups. Plasma cholecystokinin levels in children of 10 years of age and under (54.5 +/- 40.4 pg/mL) were significantly lower (p = 0.01) than in children over 10 years (79.1 +/- 59.8 pg/mL). Plasma cholecystokinin levels based on colonic transit patterns, however, were not significantly different between the two age groups. There was no significant difference in plasma cholecystokinin levels between groups based on defecation frequency per week, presence of defecation pain, symptoms of milk intolerance, or the presence of emotional stress. These results suggested that there was a tendency of increasing plasma cholecystokinin levels in the younger age group and in children with delay in proximal colonic transit, but further study is required in relation to plasma cholecystokinin levels based on colonic transit patterns in a large number of patients.

Topics: Abdominal Pain; Child; Cholecystokinin; Colon; Female; Gastrointestinal Transit; Humans; Male; Recurrence

A high dose of cholecystokinin (CCK) agonist cerulein can induce acute pancreatitis in animals. The role of CCK in the induction of acute pancreatitis in humans is unclear. We investigated basal plasma CCK levels before and after induction of post-ERCP pancreatitis to determine CCK levels in the early course of the disease.. We determined plasma CCK concentrations in four groups of patients who underwent ERCP: (1) post-ERCP pancreatitis patients (n = 23); (2) patients with post-ERCP hyperamylasemia without pancreatitis (n = 5); (3) patients with post-ERCP abdominal pain without hyperamylasemia (n = 18); and (4) patients with an uneventful post-ERCP period (n = 43). Plasma samples were taken before ERCP, 4 to 8 hours, 10 to 16 hours, and 24 hours after ERCP. Plasma CCK concentrations were determined by a specific and sensitive radioimmunoassay using CCK antiserum (Euro-Diagnostica, Malmö, Sweden).. Plasma CCK levels increased five-fold early in the course in post-ERCP pancreatitis patients, but not in post-ERCP hyperamylasemia patients or in uncomplicated ERCP patients, where CCK levels temporarily decreased after ERCP. In patients with abdominal pain, CCK levels did not change. After the early increase, plasma CCK levels declined to almost unmeasurable levels one day after the onset of symptoms in post-ERCP pancreatitis. In other groups CCK levels were close to the pre-ERCP level.. It remains to be shown whether CCK is important in the pathogenesis of post-ERCP pancreatitis or merely a secondary phenomenon. There is a rationale to test CCK antagonists in preventing post-ERCP pancreatitis.

Topics: Abdominal Pain; Amylases; Case-Control Studies; Cholangiopancreatography, Endoscopic Retrograde; Cholecystokinin; Female; Humans; Male; Middle Aged; Pancreatitis; Prospective Studies; Radioimmunoassay; Time Factors

Abdominal pain in patients with chronic pancreatitis has been related to an increase in plasma cholecystokinin (CCK) levels. The aim of the study was to disclose the relation of the altered response with the low intraduodenal bile acids levels found in these patients. Twenty patients with chronic pancreatitis were classified into groups I (n = 11) and II (n = 9) according to the presence or absence of pain. Intraduodenal trypsin and bile acids concentrations and plasma CCK levels were measured before and 30, 60, and 90 min after a test meal. Comparisons between values in both groups were carried out. Correlation of intraduodenal trypsin and bile acids with plasma CCK was analyzed. Patients with pain exhibited significantly lower intraduodenal trypsin levels at 30 and 90 min and lower basal and postprandial intraduodenal bile acids levels than patients without pain. In patients with pain, basal and postprandial plasma CCK levels were significantly higher than in patients without pain. A negative correlation was demonstrated between intraduodenal bile acids and plasma CCK. In patients with chronic pancreatitis and pain, a reduction in intraduodenal postprandial trypsin and basal and postprandial bile acids concentrations, as well as an increase in basal and postprandial plasma CCK levels, was encountered. A negative correlation between intraduodenal bile acids and plasma CCK concentrations was detected that may be implicated in the pathogenesis of pain.

Topics: Abdominal Pain; Bile Acids and Salts; Cholecystokinin; Duodenum; Food; Humans; Kinetics; Pancreatitis; Trypsin

Topics: Abdominal Pain; Cholecystectomy; Cholecystokinin; Cholelithiasis; Humans; Predictive Value of Tests

Medium-chain triglycerides are known to induce diarrhea, possibly resulting from accelerated intestinal transit. We performed antroduodenal manometry and lactulose hydrogen breath testing simultaneously in eight healthy subjects in order to determine the effects of intraduodenally administered medium-chain triglycerides (MCT) and long-chain triglycerides (LCT) on gastrointestinal motility and small bowel transit time. LCT (15 mmol/hr) induced a fed motor pattern. In contrast, during MCT, in both equimolar (15 mmol/hr; MCT-1) and equicaloric (30 mmol/hr; MCT-2) amounts comparable to LCT, interdigestive motility was preserved but with a significantly (P < 0.05) shorter MMC cycle length (MCT-1, 65 +/- 7 min; MCT-2, 53 +/- 6 min) compared to control (saline infusion; 127 +/- 14 min). Duodenocecal transit time (DCTT) was significantly (P < 0.05) accelerated during administration of MCT (MCT-1, 56 +/- 6 min; MCT-2, 69 +/- 9 min) and was not affected by LCT (105 +/- 13 min) when compared to control (101 +/- 9 min).. MCT, in contrast to LCT, preserve interdigestive motility with a shorter MMC cycle length and accelerate DCTT.

Topics: Abdominal Pain; Adult; Cecum; Cholecystokinin; Diarrhea; Duodenum; Female; Gastrointestinal Motility; Gastrointestinal Transit; Humans; Male; Manometry; Sodium Chloride; Triglycerides

The objective of the present study was to measure plasma concentrations of the gastrointestinal hormones gastrin, somatostatin and cholecystokinin in plasma of children with recurrent abdominal pain, since these hormones affect gastrointestinal function. Forty-four children (7-16 years old) with recurrent abdominal pain and 36 control children (matched for age and sex) participated in the study. In a blood sample collected after an overnight fast, gastrin, somatostatin and cholecystokinin concentrations were measured by radioimmunoassay. The children with recurrent abdominal pain had higher plasma cholecystokinin levels (p < 0.001) than the controls. Whether or not this aberration is related to the clinical symptoms of children with recurrent abdominal pain remains to be established.

Topics: Abdominal Pain; Adolescent; Child; Cholecystokinin; Female; Gastrins; Humans; Male; Recurrence; Somatostatin

We have investigated the relationship between cholecystokinin levels and abdominal pain in patients with chronic pancreatitis. The baseline and postprandial cholecystokinin levels were measured in 15 patients with chronic pancreatitis (8 with and 7 without abdominal pain) and in a reference group of 8 healthy subjects. The baseline, 30 and 60 min postprandial plasma cholecystokinin levels were significantly (p less than 0.05) higher in the patients with pain as compared with the other two groups. No correlation was observed between increased cholecystokinin levels and impairment of the exocrine pancreatic function as assessed by the NBT-PABA test. The increased cholecystokinin levels might be an important factor in the genesis of pain in chronic pancreatitis.

Topics: Abdominal Pain; Adult; Cholecystokinin; Chronic Disease; Female; Food; Gastrins; Humans; Male; Pancreatitis; Radioimmunoassay

Future treatments of functional intestinal disorders (FID) are essentially dependent on the possible pathophysiologic hypotheses. Schematically, symptoms experienced by patients with FID can be attributed to intestinal (small or large intestine) motor disturbances or to visceral sensitivity derangement, which, in turn, may be primary or secondary to an anomalous response to alimentation, liberation of hormones or neuromediators, or to a "stress" situation. New therapeutic agents can be directed against the symptoms experienced by patients (? action on pain or intestinal transit disorders) or against the initial pathophysiologic mechanisms. In the treatment of functional diarrhea, several substances have been proposed recently. Encephalines are peptides with extremely short duration of action which are degraded by two membranous enzymes, encephalinase and carboxypeptidase. Recently, it has been shown that acetorphan, an inhibitor of encephalinase, is efficacious in acute diarrhea. Alpha-2-antagonists are substances which are capable of slowing intestinal transit time and increasing intestinal absorption. Their antidiarrheic action is moderate, and they do not act on abdominal pain. Molecules that do not traverse the neuromeningeal barrier but that act selectively on the digestive tract and are better tolerated are expected. In patients complaining of severe idiopathic constipation substances capable of stimulating colonic motility are useful: substance P or neurotensin analogues might prove interesting. Antagonists of opium receptors such as Naloxone have proved efficacious in the treatment of certain cases of chronic idiopathic intestinal pseudo-obstructions or severe constipation. The development of orally active substances or with hepatic elimination are a prerequisite. Therapy based on well characterized pathophysiologic abnormalities would be welcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Abdominal Pain; Antidiarrheals; Benzodiazepines; Cholecystokinin; Colonic Diseases, Functional; Constipation; Diarrhea; Female; Humans; Male; Proglumide