Chronic cholecystitis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vendhan Ramanujam M.B.B.S [2]

Definition

Chronic cholecystitis is a chronic inflammatory disease of the gallbladder with histological evidence of chronic inflammation like large range of related inflammatory epithelial changes including mononuclear infiltrate, fibrosis, thickening of muscular layer, dysplasia, hyperplasia and metaplasia.[1]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Chronic cholecystitis does not have life-threatening causes; however, if chronic cholecystitis is complicated by an acute process, it can be by itself life threatening.

Common Causes

Management

Shown below are algorithms depicting the diagnostic and therapeutic approach of chronic cholecystitis according to the Society for Surgery of the Alimentary Tract (SSAT),[3] the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES),[4] the Tokyo guidelines for management of cholecystitis,[5] and review of data from multiple studies on acalculous cholecystitis.[6]

 
 
Characterize the symptoms:
❑ Recurrent biliary type abdominal pain with or without fever
❑ Recurrent abdominal bloating
❑ Unstable stool with constipation/diarrhea
❑ Weight loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
Febrile
Jaundice
Murphy's sign
❑ Nonspecific finding
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Probable diagnosis:
❑ Chronic cholecystitis
Consider alternative diagnosis:
Biliary colic
Cholangiocarcinoma
Choledocholithiasis
Cholelithiasis
Gallbladder cancer
❑ Gallbladder mucocele
Peptic ulcer disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order laboratory tests:
❑ CBC
❑ BMP
❑ CRP
❑ Total bilirubin
❑ Direct bilirubin
❑ Albumin
❑ AST
❑ ALT
❑ Alkaline phosphatase
❑ GGT
❑ Amylase
❑ Lipase
Order imaging studies:
TAUSG
CT abdomen
HIDA scan
Cholecystokinin stimulated HIDA scan
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic criteria:
❑ Chronic biliary symptoms
❑ Absence of other pain sources during CT
❑ Stone-free TAUSG
❑ Delayed gallbladder isotope accumulation, irregular gallbladder filling, or photopenic areas and septations during HIDA cholescintigraphy
❑ Low EF (<35%) in cholecystokinin stimulated HIDA scan
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Confirm chronic cholecystitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Uncomplicated chronic cholecystitis:
❑ Elective cholecystectomy
 
Complicated chronic cholecystitis:
Appropriate management of complications
Acute on chronic cholecystitis
Gallbladder carcinoma
Gallstone ileus
 

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BMP: Basic metabolic profile; CBC: Complete blood count; CRP: C-reactive protein; CT: Computed tomography; EF: Ejection fraction; GGT: Gamma-glutamyl transpeptidase; HIDA scan: Hepatobiliary iminodiacetic acid scan; TAUSG: Transabdominal ultrasonography

References

  1. Zhou, D.; Guan, WB.; Wang, JD.; Zhang, Y.; Gong, W.; Quan, ZW. (2013). "A comparative study of clinicopathological features between chronic cholecystitis patients with and without Helicobacter pylori infection in gallbladder mucosa". PLoS One. 8 (7): e70265. doi:10.1371/journal.pone.0070265. PMID 23936177.
  2. Kimura, Y.; Takada, T.; Kawarada, Y.; Nimura, Y.; Hirata, K.; Sekimoto, M.; Yoshida, M.; Mayumi, T.; Wada, K. (2007). "Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg. 14 (1): 15–26. doi:10.1007/s00534-006-1152-y. PMID 17252293.
  3. Duncan, CB.; Riall, TS. (2012). "Evidence-based current surgical practice: calculous gallbladder disease". J Gastrointest Surg. 16 (11): 2011–25. doi:10.1007/s11605-012-2024-1. PMID 22986769. Unknown parameter |month= ignored (help)
  4. Overby, DW.; Apelgren, KN.; Richardson, W.; Fanelli, R.; Overby, DW.; Apelgren, KN.; Beghoff, KR.; Curcillo, P.; Awad, Z. (2010). "SAGES guidelines for the clinical application of laparoscopic biliary tract surgery". Surg Endosc. 24 (10): 2368–86. doi:10.1007/s00464-010-1268-7. PMID 20706739. Unknown parameter |month= ignored (help)
  5. Mayumi, T.; Someya, K.; Ootubo, H.; Takama, T.; Kido, T.; Kamezaki, F.; Yoshida, M.; Takada, T. (2013). "Progression of Tokyo Guidelines and Japanese Guidelines for management of acute cholangitis and cholecystitis". J UOEH. 35 (4): 249–57. PMID 24334691. Unknown parameter |month= ignored (help)
  6. Huffman, JL.; Schenker, S. (2010). "Acute acalculous cholecystitis: a review". Clin Gastroenterol Hepatol. 8 (1): 15–22. doi:10.1016/j.cgh.2009.08.034. PMID 19747982. Unknown parameter |month= ignored (help)


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