Gallbladder Problems Common In Celiac Disease May Be Missed By Doctors Because Of Normal Tests

Gallbladder disease is a common condition typically affecting young and otherwise healthy individuals. Risk factors include obesity, diabetes, female gender, pregnancy, family history, rapid weight loss, liquid protein diets, and race or ethnic background. When typical symptoms of right sided upper abdominal pain, nausea, vomiting, and bloating occur within 15-90 minutes of eating, especially a fatty meal, gallstones are usually suspected. Ultrasound of the gallbladder is the first test ordered and will confirm the presence or absence of gallstones. If gallstones are confirmed then surgical removal of the gallbladder is recommended.

However, if the ultrasound is negative or normal and gallbladder disease is still suspected a nuclear test called biliary scintography or more commonly called HIDA scan is ordered. The basis of this test is the fact that a radiolabeled chemical is administered intravenously that is concentrated in the liver where bile is made before being stored in the gallbladder between meals. If the gallbladder is diseased it may fail to be seen on the scan due to blockage or fail to empty as expected when a hormone called cholecystokinin (CCK) is given intravenously. CCK is present in the body and released with meals to stimulate gallbladder emptying of bile into the intestine for digestion. Typically, the gallbladder will empty a third or more of its volume when CCK is given during a HIDA scan but usually not more than 70-80%. The fraction of volume the gallbladder empties is referred to as the ejection fraction. A low ejection fraction is typical of a diseased gallbladder. Reproduction of the typical pain of gallbladder disease and a low ejection fraction are considered diagnostic of gallbladder disease in the absence of gallstones and results in a recommendation that the gallbladder be removed surgically.

An unusual phenomenon has been observed in some Celiac patients. Gallbladder type abdominal pain without gallstones and a “supranormal” gallbladder ejection fraction. Surgery relieves the gallbladder type pain and a diseased gallbladder is found. Radiology studies have been reported in the literature that shed light on this phenomenon though it’s significance has been largely missed by the medical community.

Various ultrasound findings have been reported in Celiac disease, primarily in the European literature. Colli et. al in Italy noted increased fasting volumes of the gallbladder by ultrasound in untreated Celiac patients and Mariciani et. al. in the U.K. found increased gallbladder volumes and elevated gallbladder ejection fractions using MRI. Low CCK levels have been reported in Celiac patients (Deprez 2002, Rehfeld 2004). This physician has had several Celiac disease patients who have had high gallbladder ejection fractions (typically >90%) associated with classic gallbladder symptoms that resolved after gallbladder surgery. Chronic gallbladder disease was confirmed pathologically.

Gallbladder disease should be considered in Celiac disease patients despite normal ultrasound and HIDA tests, especially if a “supranormal” ejection fraction is noted and pain reproduced with CCK. Patients with abnormal high gallbladder ejection fractions should be considered as possible undiagnosed Celiacs and should undergo blood tests for Celiac disease and consideration of upper endoscopy with small bowel biopsy.

1. Fraquelli M; Colli A; Colucci A; Bardella MT; Trovato C; Pometta R; Pagliarulo M; Conte D. Accuracy of ultrasonography in predicting celiac disease. Arch Intern Med. 2004; 164(2):169-74.

2. Marciani L; Coleman NS; Dunlop SP; Singh G; Marsden CA; Holmes GK; Spiller RC; Gowland PA. Gallbladder contraction, gastric emptying and antral motility:single visit assessment of upper GI function in untreated celiac disease using echo-planar MRI. J Magn Reson Imaging. 2005; 22(5):634-8.

3. Deprez P; Sempoux C; Van Beers BE; Jouret A; Robert A; Rahier J; Geubel A; Pauwels S; Mainguet P. Persistent decreased plasma cholecystokinin levels in celiac patients under gluten free diet:respective roles of histological changes and nutrient hydrolysis. Regul Pept. 2002;110(1):55-63

4. Rehfeld JF. Clinical endocrinology and metabolism. Cholecystokinin. Best Pract Res Clin Endocrinol Metab. 2004; 18(4):569-86.

Michael Ortiz

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