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Treatment Of Gallbladder Dyskinesia
In Children With Acupuncture
Ivan Figueroa Otero, MD
Jose Russe, MD
ABSTRACT
Background Gallbladder dyskinesia is a presumptive diagnosis of a gallbladder dysfunction that presents with gallstone-free biliary type of abdominal pain in patients who have delayed gallbladder emptying on cholecystokinin-stimulated hepatobiliary scans. In view of the high incidence of residual and recurrent symptoms reported in these patients after cholecystectomy, acupuncture may be an initial alternative prior to surgical management.
Objective To determine if medical acupuncture in patients with gallbladder dyskinesia would alleviate their symptoms and postpone the need for urgent surgery.
Design, Setting, and Patients A retrospective review of 10 patients (9 girls and 1 boy; mean age, 16 years), with a mean duration of symptoms of 11 months, who fulfilled the diagnostic criteria by biliary scan and had a minimum of 4 treatment sessions of acupuncture. All patients were considered surgical candidates by a referring pediatric gastroenterologist.
Intervention The treatment sessions were scheduled at weekly intervals with a mean of 5 sessions per patient. Treatment consisted of 3-6 acupuncture points, based on the specific alteration according to Chinese syndromes. The needles were placed unilaterally and De Qi was obtained prior to sedation or tonification. The most frequently used were LR 3 and GB 34 for dispersing the liver; SP 6, ST 36, SP 4, SP 3, and CV 12 for tonifying the stomach and spleen; CV 12, ST 21, and SP 9 for dispersing Qi, and damp and food stagnation; and PC 6, ST 36, CV 10, and CV 13 for controlling the countercurrent Qi of the stomach.
Main Outcome Measures Subjective symptom improvement and the parents' objective assessment of their children's clinical signs after acupuncture. Further hospitalizations and any surgical management were determined.
Results All 10 patients improved significantly after the 1st 2 treatments and were asymptomatic within 4-7 treatments. Two patients within 12 months presented with recurrent moderate symptoms, but both responded rapidly with 2 additional treatments. At 2 years of follow-up, 8 patients were symptom-free and none required surgical intervention.
Conclusions The results of this small series of cases suggest that acupuncture could be an initial alternative to cholecystectomy for gallbladder dyskinesia in children. Further clinical and laboratory research should be performed to confirm these findings and to determine the physiologic basis of the harmonizing effects on the gastrointestinal tract.
KEY WORDS
Biliary Dyskinesia, Acalculous Cholecystitis, Hepatobiliary Scan, Acupuncture, Cholecystectomy, Gallbladder Ejection Fraction
INTRODUCTION
Biliary dyskinesia is a controversial diagnosis for patients who present with gallstone-free biliary type of abdominal pain and have delayed gallbladder emptying on cholecystokinin-stimulated hepatobiliary scans. An ejection fraction of less than 35% has been traditionally considered diagnostic.
A high incidence of residual symptoms after surgery is reported to range from 10%-70%.1-6 The series reporting the best surgical results have characteristically lacked long-term follow-up results and specificity in the signs of clinical improvement.7,8 Acupuncture treatment may be an alternative for patients prior to considering surgical management.
METHODS
A review of all patients referred for treatment who had completed a minimum of 4 acupuncture sessions were included. Written informed consent was obtained from the parents or legal guardians with an explanation of therapeutic alternatives. All but 1 patient fulfilled the diagnostic criteria of an ejection fraction of less than 35%,9 did not respond to a trial of medical therapy, and were considered surgical candidates by a referring pediatric gastroenterologist.
Flexible esophagogastroduodenoscopies and indicated blood tests were performed in the majority of patients, including complete blood cell count, urinalysis, liver enzymes, serum lipase, serum amylase, and Helicobacter pylori. In addition to an allopathic history and examination, a detailed history and examination was done using Traditional Chinese Medicine (TCM) based on the 8 principles and syndrome differentiation. On physical examination, pulse and tongue examinations were used to complete the TCM diagnosis.
The sample consisted of 10 patients (9 girls and 1 boy), ranging in age from 12-18 years (mean,16 years). No abnormalities were found in the blood tests. The duration of symptoms prior to surgical evaluation ranged from 3-24 months (mean, 11 months). A family history of gallbladder disease was noted in 3 patients. A relatively high incidence of peptic ulcer disease (n=3) was documented in the parents; in 1 patient, both parents had undergone surgeries for gallbladder dyskinesia. Previous psychological counseling was documented in 4 patients.
The degree of severity of the clinical signs was emphasized by the high rate of hospitalizations: 5, median stay of 9 days. The most frequently presenting symptoms were nausea (n=9), heartburn, gastroesophageal reflux (n=9), and fatty food intolerance (n=7). The additional distribution of symptoms is shown in Figure 1. The ejection fraction values ranged from 12%-37% (mean, 18%). No correlation was found between this test and the severity of symptoms. The endoscopic findings of the patients are shown in Table 1.
The most frequently found Chinese clinical syndromes are presented in Table 2. Most frequently seen were Liver Qi stagnation with disharmony of the liver and spleen (n=8), Spleen Qi insufficiency (n=8) and stagnation of Qi, and dampness and food in the Middle Burner, usually the resulting excess condition of the previous imbalances. A combination of deficiency and excess conditions resulted in the symptoms. Emotional stress could explain the liver Qi stagnation (excess), and poor dietary habits and heredity could be the causative factor of spleen deficiency.
TREATMENT
Therapy was planned according to TCM diagnoses and performed by the main author. Acupuncture treatment sessions were scheduled at 1-week intervals; the average number of sessions prior to discharge was 4-7 (mean, 5 sessions). The selection of acupuncture points varied among patients, dependent on the clinical syndrome diagnosis established in TCM. The therapy rationale involved dispersing liver stagnation, sedating the excess in the middle burner, tonifying the spleen or stomach weakness, and rectifyng the countercurrent Qi associated with nausea and gastroesophageal reflux. Three to 6 points were used each session, using stainless steel Vinco needles (Helio Medical Supplies Inc.) of 0.25 gauge and 25 or 40 mm length, inserted in a unilateral balanced manner obtaining De Qi at all times. After De Qi, tonification was obtained by rapid clockwise short rotations (30°-45°), and dispersion and sedation were obtained by ample counterclockwise slow rotations (180°-360°). The needles were left in place without further manipulation for 20 minutes. The most frequently used points for dispersing the liver were LV 3 Taichong and GB 34 Yanglingquan. For tonifying the spleen and stomach, SP 6 Sanyinjiao, ST 36 Zusanli, SP 4 Gongsun, SP 3 Taibai, and CV 12 Renmai were used. For dispersing Qi and food and damp stagnation, CV 12 Renmai, ST 21 Liangmen, and SP 9 Yinlingquan were used. For controlling countercurrent Qi (nausea, vomiting, and gastroesophageal reflux), PC 6 Neiguan, ST 36 Zusanli, CV 10 and CV 13 Renmai were used.
Most of the children were apprehensive of needles but, careful explanation of the procedure using guided introducers and allowing time to realize that the initial De Qi sensation was transitory, ensured a tolerable experience. The majority of patients, aided by background music and water effects, relaxed by the 2nd treatment session.
RESULTS
Significant improvement of symptoms was noted after the 2nd session of acupuncture. All the patients became asymptomatic within 4-7 treatments (mean, 5 treatments).
Of the patients who were followed over 12 months, 2 had recurrence with moderate symptoms at around 1 year following treatment, but both responded rapidly within 2 additional therapies.
One of these patients was referred for arthralgias, fibromyalgia , a positive liver enzyme test result, and associated digestive problems. This patient was seen 31/2 years after initial treatment; she had gained excessive weight associated with poor dietary habits and presented
with mild heartburn and occasional nausea. She has not incurred surgical intervention (this patient had the best ejection fraction [37%]).
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Figure 1. Distribution of Patient Symptoms
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The 2nd patient with recurrence was a severely obese girl exhibiting severe school social adaptation anxiety associated with her weight.
Although the size of the group was too small to obtain statistical significance, resolution of symptoms was observed in 8 of the cases, and was noted in 9 cases in the group with an ejection fraction of less than 35%.
DISCUSSION
The mechanism of action of acupuncture in Western medicine has been mainly directed and documented toward its role in analgesia.
Several studies have suggested explanations based on the modulation of the autonomic system and systemic liberation of endorphins.10,11 For those trained in TCM, it is relatively easy to understand the logical rationale of picking a combination of points based on the 8 principles and syndromes to control the gastrointestinal symptoms. Yet we lack the scientific basis for these remarkably expedient results.
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Table 1. Endoscopic Findings
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Endoscopic
Findings
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No. of Patients
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Enterogastric bile reflux
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6
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Esophagitis
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6
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Duodenal uder
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2
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Gastric ulcer
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1
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Although Chinese medical literature is full of empirical documentation of acupuncture in gastrointestinal problems, only sporadic clinical series are presented in Western peer-reviewed publications.12,13 Several series have documented acupuncture's ability to control nausea and vomiting in early pregnancy, which suggests a direct harmonizing effect over the neuroendocrine mechanism of the gastrointestinal tract.14
The specificity of the hepatobiliary scan in determining selective involvement of biliary disease is questioned due to its occurrence in other conditions of the gastrointestinal tract,1,15 and the high incidence of recurrent symptoms when the ejection fraction falls between 14%-35%.6 This suggests that the test is a reflection of a more generalized dysfunction of the previously mentioned system. Clinicians should be aware that removal of the gallbladder in both calculous and acalculous disease removes only the symptoms related to the organ itself such as colics and inflammation, and not the associated gastrointestinal signs such as heartburn, reflux, and fatty food intolerance.3
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Table 2. Chinese Clinical Syndromes
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Clinical Syndrome
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No. of Patients
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Liver Qi stagnation
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8
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Spleen Qi deficiency
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8
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Qi, damp, and food stagnation
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5
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Blood deficiency
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3
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Damp heat Middle Burner
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3
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Lung Qi deficiency
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2
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Kidney Yin deficiency
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2
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Stomach Yin deficiency
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1
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CONCLUSION
The results within this small series of cases suggest that if the findings were reproduced with a larger population and longer follow-up, acupuncture may be an initial safe alternative to cholecystectomy in children. We encourage additional investigation of the physiological effects of acupuncture in gastrointestinal diseases.
REFERENCES
- Goncalves RM, Harris JA, Rivera DE. Biliary dyskinesia: natural history and surgical results. Am Surg. 1998;64(6):493-498.
- Cunningham CC, Sehon JK, Johnson LW, Zibari GB. Outcomes of surgical therapy for biliary dyskinesia. J La State Med Soc. 2003;155(4):189-191.
- Tabet J, Anvari M. Laparoscopic cholecystectomy for gallbladder dyskinesia: clinical outcome and patient satisfaction. Surg Laparosc Endosc Percutan Tech. 1999;9(6):382-386.
- Hadigan C, Fishman SJ, Connolly LP, Treves ST, Nurko S. Stimulation with fatty meal (lipomul) to assess gallbladder emptying in children with acalculous cholecystitis. J Pediatr Gastroenter Nutr. 2003;37(2):178-182.
- Gall CA, Chambers KJ. Cholecystectomy for gallbladder dyskinesia: symptom resolution ans satisfaction in a rural practice. Aust N Z J Surg. 2002; 72(10): 731-734.
- Bingener J, Richards ML, Schwesinger WH, Sirinek KR. Laparoscopic cholecystectomy for biliary dyskinesia: correlation of preoperative cholecystokinin cholencintigraphy results with postopetaive outcome. Surg Endosc. 2004. Electronic publication ahead of print.
- Lugo-Vicente HL. Gallblader dyskinesia in children. JSLS. 1997;1(1):61-64.
- Gollin G, Raschbaum GR, Moorthy C, Santos L. Cholecystectomy for suspected biliary dyskinesia in children with chronic abdominal pain. J Pediatr Surg. 1999;34(5):854-857.
- Ozden N, Dibaise JK. Gallbladder ejection fraction and symptom outcome in patients with acalculous biliary-like pain. Dig Dis Sci. 2003;48(5): 890-897.
- Anderson S, Lundberg T. Acupuncture-from empiricism to science: functional background to acupuncture effects in pain and disease. Med. Hypotheses. 1995;45(3):271-281.
- Pintov S, Lahat E, Alstein M, Vogel Z, Barg J. Acupuncture and the opioid system: implications in management of migraine. Pediatr Neurol. 1997; 17(2):129-133.
- Li Y, Tougas G, Chiverton SG, Hunt RH. The effect of acupuncture on gastrointestinal function and disorders. Am J Gastroenterol. 1992;87(10): 1372-1381.
- Fireman Z, Segal A, Kopelman Y, Sternberg A, Carasso R. Acupuncture treatment for irritable bowel syndrome. a double-blind controlled study. Digestion. 2001;64(2):100-103.
- Smith C, Crowther C, Beilby J. Acupuncture to treat nausea and vomiting in early pregnancy: a randomized controlled clinical trial. Birth. 2002;29(1):1-9.
- Hemingway D, Neilly JB, Finlay IG. Biliary dyskinesia in idiopathic slow transit constipation. Dis Colon Rectum. 1996;39(11):1303-1307.
AUTHORS' INFORMATION
Dr Ivan Figueroa Otero is a Board-certified Pediatric Surgeon, Licensed Acupuncturist, Associate Professor of Surgery at University of Puerto Rico School of Medicine, and Senior Attending Physician in Pediatric Surgery at University of Puerto Rico Pediatric Hospital in San Juan, Puerto Rico.
Ivan Figueroa Otero, MD, FACS, FAAP, LicAp*
252 San Jorge St, Ste 407
San Juan, PR 00912
Phone: 787-728-1415
Fax: 787-728-1409
E- mail: ifigueroa@prtc.net
Dr Jose Russe is a Pediatric Gastroenterologist at San Jorge Children's Hospital in San Juan, Puerto Rico.
Dr Jose I. Russe, MD, FAAP
252 Convento St
San Juan, PR 00912
Phone: 787-726-1113
*Correspondence and reprint requests
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