Biliary dyskinesia: traditional and modern views

Traditional and modern views on pathogenesis, clinical manifestations, diagnosis and treatment of the gallbladder and biliary sphincters dysfunctions are analyzed in the article. Functions of bile and its role in the process of digestion are highlighted. Diagnostic criteria for biliary dysfunctions are described in detail in accordance with the Rome Consensus IV (mandatory and confirmatory); clinical and diagnostic criteria for the classical variants of biliary dyskinesia, namely hypo- and hyperkinetic dyskinesia of the gallbladder, are being presented. Treatment of biliary dysfunctions is described according to the Rome Consensus IV, taking into account the type of dyskinesia. It is reasonable to follow the basic principles of dietary nutrition in diseases of the biliary tract, as well as to protect the mucous membrane of the upper gastrointestinal tract from mechanical, thermal and chemical effects. It is important to eat in a relaxed atmosphere, not in a hurry. The antispasmodics that are used for biliary dysfunctions are listed: M-cholinolytics, myotropic antispasmodics, calcium and sodium channel blockers, etc. Importance of ursodeoxycholic acid in treatment of functional biliary diseases is emphasized. The use of ursodeoxycholic acid preparations in biliary dyskinesia is based on its ability to reduce the lithogenicity of bile, as well as exert an anti-inflammatory effect on the mucous and muscular layer of the biliary tract, which indirectly contributes to the normalization of impaired motility and secretion. Advantages of the combined drug Engilen consisting of milk thistle, artichoke and turmeric are highlighted. With the ineffectiveness of conservative treatment and the results of the examination, confirming structural changes (stenosis) in the ending area of common bile and/or pancreatic duct, decision on endoscopic treatment can be made.

In a word, everything that we eat for lunch!

N. Knushevitskaya
The epigraph, although it has a playful (unscientific) hue, but, of course, reflects the important role of bile in the digestion process.
The main functions of bile in the digestive tract are as follows.

Participation in the digestive process:
splitting and assimilation of neutral fat; stimulation of pancreatic function (due to bile acids). and increased visceral sensitivity, i.e., sensitivity of the walls of the biliary tract. In this case, structural (organic) pathology, for example, cholecystitis, gallstones, is not detected [3].
Dyskinesia of gallbladder (GB) and sphincter of Oddi (OS) are dyskinesia. The latter, in turn, is divided into biliary type dyskinesia and pancreatic type dyskinesia.
In the first case, symptoms from the bile ducts prevail, in the second from the pancreas (see below). Timely diagnosis and treatment of functional biliary disorders is important both from the point of view of improving the well-being of patients, and that functional diseases can serve as a starting point and basis for further progression of biliary tract diseases up to cholelithiasis (Fig. 1).
Dyskinesia of the gastrointestinal tract and sphincter apparatus of the biliary tract are often diagnosed already in childhood. Using a retrospective analysis, it was possible to find out that many of these children were brought up in single-parent families (without a father) or lived with their stepfather, in an atmosphere of frequent family conflicts and quarrels. In this regard, they grew up as closed, unsociable children, deprived of parental affection, often experienced grievances from their peers, felt lonely, abandoned. The consequence of these psycho-traumatic influences was the development of child psychogeny. Most likely, it was children's psychogeny and personality neurotization that became one of the reasons for the development of dyskinesia of the gastrointestinal tract and biliary tract, which was previously associated with the formation of this type of charactercholeric (from the Greek The high prevalence of biliary dyskinesia in the modern world can be explained by the "epidemic" of obesity and the associated tendency to form lithogenic bile and the development of an inflammatory reaction in the stomach. As Igor Huberman accurately and figuratively noted: -The world is exhausted from bile, the planet is sick with liver...‖ Biliary dyskinesia is diagnosed in 10-20% of patients, more often in women. The higher incidence of women can be explained by the influence of female sex hormones (estrogens) on the lithogenic potential of bile (a tendency to stone formation) and motility of the biliary tract, as well as more frequent seeking medical help.
In recent years, in industrialized countries there has been a tendency to increase the frequency of diagnosis of biliary dysfunction along with an increase in the prevalence of other functional diseases of the digestive system. This can be explained by the lifestyle features of modern residents of developed countries (excessive carbohydrate content in food and insufficient motor activity, resulting in an increased risk of lithogenic bile formation and biliary tract motility), an -epidemic‖ of obesity, and the emergence of highly accurate examination methods [3].  pain does not decrease after stool;  pain does not decrease after taking antacids or proton pump inhibitors.
Confirming (optional) criteria for biliary pain.
Pain may be combined with one or more of the following symptoms:  arise after unrest, less often after food provocation and physical exertion;  pains are not so intense and not so long as with gallstone disease;  pass independently, from applying heat to the right hypochondrium or after taking antispasmodics;  rarely there is irradiation (if there is, then in the right shoulder blade);  pain is not accompanied by vomiting (but nausea is possible), jaundice, fever;  more than half of patients experience discomfort in the heart, tachy-or bradycardia;  patients are emotionally labile, sometimes autonomic dysfunction is determined (sweating, easily redden, unstable blood pressure), some patients are choleric;  reaction from the liver (reactive hepatitis, i.e., its increase, soreness) does not happen;  with palpation at the height of the attack, pain (but not resistance) in the projection of the ventricle is determined, the objective symptoms of cholecystitis are negative.
Features of clinical manifestations of dysfunction of the pancreas by hypokinetic type: pain does not have the nature of attacks; pains are dull, aching, spilled, non-intense; pain can be constant with periodic intensification or periodic, but lasts from 30 minutes to several hours; pain occurs at night, with long breaks between meals; pain is relieved after eating, -blind‖ soundings, cholekinetics (for example, magnesium sulfate, sorbitol, xylitol, etc.); -irradiation to the right shoulder or shoulder blade is noted in less than 10% of cases; nausea, bitterness in the mouth, loss of appetite, unstable stools In the period of exacerbation of dyskinesia, it is advisable to observe the basic principles of dietary nutrition for diseases of the biliary tract, as well as protect the mucous membrane of the upper gastrointestinal tract from mechanical, thermal and chemical influences. The nature of nutrition can be approximated to diet No 5 according to M. I. Pevzner: food should be taken every 3 hours, refuse long breaks in eating, it is desirable to limit the consumption of animal fats, fried foods, extractives (strong meat and fish broths, smoked meats and canned food), spices, seasonings and spices (onions, garlic, peppers, mustard), marinades, carbonated fruit water, beer, dry white wine, champagne, coffee, citrus fruits. It is advisable to cook food mainly by boiling, stewing, baking, steaming. Within 1.5-2.0 hours after eating, prolonged inclines and horizontal position should be avoided. Dairy products (cottage cheese, kefir, low-fat yogurt), cereals (oatmeal, buckwheat) in water or low-fat milk, bananas, baked apples, mashed potatoes, vegetable soups, boiled meat (low-fat beef, chicken breast) are useful. It is also useful to take non-carbonated mineral water in a heated form, ½ cup 4 times a day half an hour before meals. Outside the period of exacerbation, the diet is expanded and, with good tolerance, meals are organized according to the usual rational principles. It is important to eat in a relaxed atmosphere, slowly [3].
You should pay attention to the normalization of the rhythm of sleep, daily routine, ensuring adequate rest. In the presence of mood disorders, psychoemotional state, it is advisable to consult a psychotherapist [1].
The following groups of drugs are indicated for the treatment of biliary  complex of treatment includes physiotherapy (sinusoidal modulated currents, low-intensity ultrasound, low-frequency pulsed current) and reflexology.
Given that biliary dysfunctions are often mixed (hypotonic-hyperkinetic or hypertonic-hypokinetic), it is advisable to choose choleretic drugs that have both choleretic and hypokinetic effects. An excellent example is the drug Angilen is a combined hepatoprotector, which includes turmeric, artichoke and silymarin. The latter has a pronounced hepatoprotective effect.
If the conservative treatment is ineffective and the examination results confirm structural changes (stenosis) in the region of the final part of the common bile and/or pancreatic duct, a decision can be made on endoscopic treatment, for example, on papillosphincterotomy.
An important place in rehabilitation after a period of exacerbations and in prevention is occupied by physical therapy, dosed walking, swimming, spa treatment in the sanatoriums of Truskavets, Morshin, etc., the use of mineral waters of small and medium mineralization (sulphate, sulphate-chloride with different cationic composition -Borzhomi, Essentuki No 4, Arzni, Smirnovskaya, Slavyanovskaya).
Effective hydrotherapy (thermal and high thermal water), physiotherapeutic procedures that have antispasmodic and anti-inflammatory effects.
I would like to end with a statement by D. Pisarev -If there is no bile and laughter, there is no hope of renewal‖.