Chronic cholecystitis resident survival guide

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.

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

• Calculous cholecystitis

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), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the Tokyo guidelines for management of cholecystitis, review of data from multiple studies on acalculous cholecystitis, and American Roentgen Ray Society (ARRS).

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: ❑ Fever ❑ Jaundice ❑ Murphy's sign ❑ No specific finding

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

Confirmed 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

Do's

• Always consider chronic cholecystitis in the setting of cholelithiasis.
• HIDA scan should complement TAUSG and CT scan whenever the diagnosis is uncertain as well as to differentiate it from acute from chronic cholecystitis.
• Consider prophylactic cholecystectomy in case of porcelain gallbladder because of its association with gallbladder carcinoma. It is best seen on CT scan as plaques or punctuate foci of mural calcification.
• Although chronic cholecystitis may mimic gallbladder carcinoma, consider chronic cholecystitis in the setting of xanthogranulomatous cholecystitis when hypoattenuating mural nodules are visualized during imaging.

Dont's

• Do not delay surgical treatment in gallstone ileus because it carries a high risk of mortality rate (20–40%).

References

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