A requiem for the cholecystokinin provocation test?

Abstract

Background-The cholecystokinin provocation test (CCKPT) has been claimed to predict a better symptomatic result after cholecystectomy in patients with acalculous biliary pain. Aims-To examine the predictive value of the CCKPT for symptom relief after cholecystectomy in both CCKPT positive and negative patients. Patients and methods-Fifty eight patients with acalculous biliary pain underwent CCKPT with serial ultrasound gall bladder volumetry. CCKPT positive patients were oVered cholecystectomy; negative patients were reassessed and were oVered a cholecystectomy if symptoms persisted. Six months after cholecystectomy, the CCKPT was repeated. Results-Of 32 CCKPT positive patients, 27 underwent cholecystectomy and of these, 18 (67%) became symptom-free. Postoperatively, 20 of 25 patients converted to CCKPT negative but five remained CCKPT positive and were symptomatic. Of the 26 CCKPT negative patients, nine became symptom-free without cholecystectomy; six of 14 (42.8%) patients undergoing cholecystectomy became asymptomatic and remained CCKPT negative. Cholecystectomy seemed to reduce symptoms in both groups, but there was no significant diVerence in the symptomatic outcome between preoperative CCKPT positive and negative patients. Conclusions-In this study, cholecystokinin provocation testing did not predict symptomatic benefit from cholecystectomy and we suggest it should no longer be used in the evaluation of patients with acalculous biliary pain. (Gut 1998;43:571-574)

Anisotropic behaviour of human gallbladder walls

“…Ultrasonography of their GBs was taken to monitor initial volume, changes in shape, and volume as well as wall thickness at 5 or 15 minute intervals for 60 minutes. The test was only considered positive when the patients' usual 'gallbladder' pain was reproduced following CCK infusion (Smythe et al 1998). At point D, the sphincter of Oddi is closed, the patient is fasting, and the GB cavity volume and pressure are at their minimum levels.…”

“…The pathogenesis of such disorders is not fully understood (Parkman et al 1999). Many researchers believe that it is related to mechanical responses trigged by smooth muscle contraction of the GB (Smythe et al 1998;Parkman et al 1999;Wegstapel et al 1999;Amaral et al 2001;Merg et al 2002). The mechanical behaviour of the human GB has been extensively studied, primarily using a linear membrane ellipsoid model (Liao et al 2004;Li et al 2008;Li et al 2011a;Li et al 2011b).…”

“…We conducted linear analyses on a series of configurations of human GBs determined by ultrasonographic routine scans during emptying (Smythe et al 1998;Li et al 2008). The transmural pressure in the GBs, which was estimated from measured volume changes (Li et al 2008), was applied as the loading condition.…”

“…The patient specific constitutive constants are inversely determined from a series of ultrasonic photography images during emptying (Smythe et al 1998) using the FEM package ABAQUS, MATLAB and a Python code. To avoid modelling the active stress caused by smooth muscle cross-bridge phosphorylation during the emptying phase (Hai and Murphy 1988a;Hai and Murphy 1988b;Li et al 2011b), here the inverse computations are carried out in the refilling phase where only the passive stress is involved.…”

A Mechanical Model for CCK-Induced Acalculous Gallbladder Pain

“…It has been reported that only 50% of acalculous patients are free from pain symptoms after cholecystectomy. 50,51 A challenging task is to identify effectively these patients to reduce unnecessary surgery. Bile ejection fraction (EF), whereby the gallbladder-emptying contraction is measured by its volume change, has been used clinically, but it has been reported to be unreliable.…”