Chronic calculous cholecystitis

Chronic calculous cholecystitis is the most common disease of the gallbladder and is characterized by an almost constant combination of chronic cholecystitis and stones.

This explains the complete coincidence of etiological factors in chronic calculous cholecystitis and the formation of gallstones. Chronic inflammation can be preceded by acute cholecystitis, but usually it develops gradually.

[1], [2], [3], [4], [5]

Pathomorphology

Usually the gallbladder is reduced in size, its walls are thickened, sometimes calcified, the lumen contains turbid bile with clots, called biliary putty. Stones loosely located in the wall of the bladder or cells of the overgrown fibrous tissue, one of them is usually pinned in the neck. The mucous membrane is ulcerated and cicatricially altered, histologically marked thickening and congestive plethora of the wall with lymphatic infiltration. Sometimes the mucous membrane is completely destroyed.

[6], [7], [8], [9], [10], [11], [12], [13], [14]

Symptoms of chronic calculous cholecystitis

Due to the absence of specific symptoms, the disease is difficult to diagnose. The chronic history of cholelithiasis, postponed jaundice episodes, multiple births and obesity are evidence of chronic cholecystitis. Sometimes episodes of acute cholecystitis or seizures of biliary colic indicate chronic cholecystitis.

Abdominal distention and discomfort in the epigastric region, which are often associated with the intake of fatty foods and decrease after belching, are characteristic. Many patients complain of nausea, but in the absence of choledocholithiasis vomiting occurs rarely. In addition to the constant aching pains in the right hypochondrium, there is an irradiation to the area of the right shoulder blade, to the sternum and to the right shoulder. Alkali can ease pains that occur after eating.

Soreness to palpation of the gallbladder and a positive symptom of Murphy are characteristic.

[15], [16], [17], [18], [19]

Diagnosis of chronic calculous cholecystitis

Body temperature, white blood cell count, hemoglobin level and ESR within normal limits. On a review radiograph of the abdominal cavity, calcified gallstones can be determined, but the primary method of imaging is ultrasound, which allows you to see gallstones inside a fibrosing gallbladder with thickened walls. The inability to visualize the gallbladder also indicates its defeat. In oral cholecystography, a non-functioning gallbladder is usually found. CT can reveal gallstones, but it is not indicated for the diagnosis of chronic cholecystitis.

[20], [21], [22], [23], [24], [25], [26]

Differential diagnosis

The main symptoms of chronic cholecystitis are fat intolerance, flatulence and discomfort after eating; however, the symptoms can not always be explained by the presence of gallstones, even verified, because cholelithiasis is often asymptomatic.

To avoid unnecessary surgery, before planning cholecystectomy, other causes of such disorders should be excluded: gastric ulcer and duodenal ulcer, hiatal hernia, irritable bowel syndrome, chronic urinary tract infections and functional dyspepsia. Before surgery, you must carefully examine the psychological profile of the patient.

The presence of cholelithiasis in 10% of young and middle-aged patients may cause overdiagnosis of clinically manifested cholelithiasis. However, with the sensitivity of ultrasound and oral cholecystography, equal to about 95%, the disease of the gallbladder sometimes remains undetected.

[27], [28], [29], [30]

Differential diagnosis

The main symptoms of chronic cholecystitis are fats intolerance, bloating and discomfort after eating; at that, the symptoms are not always explained by the presence of gallstones, even if verified, as cholelithiasis is often asymptomatic.

To avoid an unnecessary surgery, before planning cholecystectomy it is necessary to rule out other causes of these disorders: stomach ulcer and duodenal ulcers, hiatal hernia, irritable bowel syndrome, chronic urinary tract infections, and functional dyspepsia. Before the operation, it is necessary to carefully examine the psychological profile of the patient.

The presence of cholelithiasis in 10% of patients of young and middle age may cause overdiagnosis of clinically appearing cholelithiasis. However, at the same time, at the sensitivity of ultrasound and oral cholecystography, equal to about 95%, gallbladder disease sometimes remains undiagnosed.

Cholecystectomy for chronic calculous cholecystitis

Cholecystectomy is indicated for the clinical manifestations of cholelithiasis, especially with repeated painful attacks. Since laparoscopic removal of common bile duct stones is technically difficult, requires special tools and goes beyond the competence of most surgeons, if you suspect choledocholithiasis before laparoscopic or traditional cholecystectomy, endoscopic cholangiography and papillosphincterotomy with extraction of calculi should be performed. An alternative approach is intraoperative cholangiography, revision of the common bile duct, removal of stones and the introduction of a T-shaped drainage.

Many postoperative complications are due to infection, so microbiological examination of bile is necessary. The T-shaped drainage is left for an average of 2 weeks; cholangiography is performed before its removal.

After uncomplicated cholecystectomy, a slight transient increase in serum bilirubin and serum transaminase activity is possible. A significant increase in these indicators indicates an unremoved stone of the common bile duct or damage to the bile ducts.

[31], [32], [33], [34]

Prognosis of chronic calculous cholecystitis

The prognosis for life with chronic cholecystitis is good, but once it appears, especially in the form of hepatic colic, the symptoms persist in the future; while the probability of a relapse within 2 years is about 40%. Very rarely does gallbladder cancer develop at an advanced stage of the disease.

With an unclear diagnosis during the observation period, it is possible to conduct conservative therapy. This is especially important with uncertain symptoms, functioning gallbladder and the presence of contraindications due to the general condition of the patient.

In obesity, measures to reduce body weight should be recommended. With a non-functioning gallbladder, a low-fat diet is indicated. Heat treatment of fats should be excluded, because its products are poorly tolerated.

[35], [36]