Chronic Cholecystitis Clinical Overview
I. The "On-Call" Snapshot
Clinical Significance in Malaysia: This is a bread-and-butter surgical diagnosis. You will encounter patients with recurrent right upper quadrant (RUQ) pain in every clinic and emergency department posting. Your job is to identify them, manage their symptoms, and refer them appropriately for definitive treatment.
High-Yield Definition: Chronic cholecystitis is a state of persistent gallbladder inflammation, almost always due to gallstones (cholelithiasis), leading to mucosal and muscular wall damage, fibrosis, and impaired gallbladder function. (Source: UpToDate, StatPearls).
Clinical One-Liner: Basically, it's a scarred, dysfunctional gallbladder that grumbles because of repeated irritation from stones.
II. Etiology & Risk Factors
Etiology: The primary cause (>95% of cases) is mechanical irritation and recurrent obstruction from cholelithiasis. These repeated episodes of biliary colic lead to chronic inflammatory changes. Acalculous cases are rare but can occur.
Risk Factors: Remember the classic "5 Fs". This is not just textbook theory; you will see it in your patients.
Fat: Obesity (BMI >30 kg/m²) increases biliary cholesterol secretion.
Female: Oestrogen increases cholesterol secretion and progesterone reduces gallbladder motility.
Forty: Risk increases with age, particularly after 40.
Fertile: Pregnancy and multiparity are significant risk factors.
Fair: More common in Western populations, but we see plenty in our multi-ethnic Malaysian population.
III. Quick Pathophysiology
It's a simple cycle. A gallstone transiently blocks the cystic duct. This increases intraluminal pressure, causing RUQ pain (biliary colic). The stone falls back, and the pain resolves. Repeat this process hundreds of times. The gallbladder wall gets repeatedly inflamed, then heals with scarring (fibrosis). The muscle layer thickens (hypertrophy), and the mucosa can herniate into the muscle wall, forming Rokitansky-Aschoff sinuses – a pathognomonic histological finding. This scarred, thick-walled gallbladder doesn't contract properly, hence the ongoing symptoms.
IV. Clinical Assessment
Red Flags & Immediate Actions: If a patient with known gallstones presents with these, they are tipping into an acute complication.
Fever ( >37.5°C) & Persistent Pain (>6 hours): Think Acute Cholecystitis. → Action: Keep nil by mouth (NBM), secure IV access, start IV fluids, take bloods (FBC, LFT, RP, CRP, GXM), and alert the surgical MO or registrar. Refer to the National Antimicrobial Guideline for IV antibiotic choices (e.g., IV Amoxicillin/Clavulanate).
Jaundice: Think Choledocholithiasis (stone in the common bile duct). → Action: Check LFT for a cholestatic picture (raised ALP, GGT, bilirubin). Alert your senior immediately; this patient may need an ERCP before any surgery.
Severe Epigastric Pain Radiating to the Back: Think Gallstone Pancreatitis. → Action: Check serum amylase/lipase. This is a medical emergency.
History:
Common (>50%): Recurrent episodes of biliary colic – a constant, dull ache in the RUQ or epigastrium, typically lasting 30 minutes to a few hours. Often precipitated by fatty meals. Associated nausea is common.
Less Common (10-50%): Vague symptoms like bloating, belching, dyspepsia, and food intolerance (especially to goreng-goreng or fatty foods).
Pertinent Negatives: Ask about fever, persistent pain, jaundice, pale stools, or tea-colored urine to rule out the red flag conditions.
Physical Examination:
Often completely normal between attacks.
During an episode of biliary colic, there may be mild to moderate tenderness in the RUQ.
A negative Murphy's sign is expected. If it's positive (inspiratory arrest on RUQ palpation), the diagnosis is acute, not chronic, cholecystitis.
Look for signs of jaundice on the sclera.
Clinical Pearl: Many middle-aged female patients will complain of "gastric." Always ask about the relationship to fatty foods and pain radiation. A good history will differentiate dyspepsia from biliary colic more often than not.
V. Diagnostic Workflow
Differential Diagnosis:
Peptic Ulcer Disease/Gastritis:
Points For: Epigastric pain, bloating, relationship to food.
Points Against: Pain is typically burning, relieved by antacids. No radiation to the back or shoulder.
How to Differentiate: An oesophagogastroduodenoscopy (OGDS) is definitive, but a trial of PPI is a reasonable first step in primary care.
Acute Cholecystitis:
Points For: RUQ pain, history of gallstones.
Points Against: Pain in chronic disease is intermittent and shorter; in acute, it is constant (>6 hours) and associated with fever and inflammatory markers.
How to Differentiate: A positive Murphy's sign on examination and ultrasound findings of pericholecystic fluid, gallbladder wall thickening >3mm, and sonographic Murphy's sign point to acute disease.
Renal Colic (Right):
Points For: Severe right-sided pain.
Points Against: Pain is usually loin-to-groin, colicky (waxing and waning), not related to meals.
How to Differentiate: Urinalysis (UFEME) looking for hematuria, and a non-contrast CT KUB if the diagnosis is uncertain.
Investigations Plan:
Bedside / Initial (Clinic Setting): Usually none required unless the patient is symptomatic.
First-Line Labs & Imaging (The Essential Workup):
Ultrasound of the Hepatobiliary System (US HBS): This is your primary diagnostic tool. You are looking for:
Cholelithiasis (the stones).
Gallbladder wall thickening (>3 mm) without pericholecystic fluid.
A contracted gallbladder.
Liver Function Test (LFT): Should be normal in uncomplicated chronic cholecystitis. An elevated ALP/GGT or bilirubin suggests a stone has moved into the CBD.
Confirmatory / Second-Line (If diagnosis is unclear):
HIDA Scan (Hepatobiliary Iminodiacetic Acid Scan): Not routinely done. Consider it for suspected biliary dyskinesia (acalculous cholecystitis) where the ultrasound is normal but the clinical suspicion is high. A low gallbladder ejection fraction (<35%) after CCK stimulation is diagnostic.
VI. Staging & Severity Assessment
Chronic cholecystitis is not staged like a cancer. The "severity" is determined by the frequency and intensity of symptoms and its impact on the patient's quality of life. The indication for surgery is symptomatic disease. Asymptomatic gallstones found incidentally are generally not operated on unless the patient is in a high-risk group (e.g., undergoing bariatric surgery, certain hemolytic anemias).
VII. Management Plan
This is an elective, not an emergency, case.
Immediate Stabilisation (For Biliary Colic Attack):
Provide analgesia. An intramuscular injection of a nonsteroidal anti-inflammatory drug (NSAID) like diclofenac 75mg is very effective if there are no contraindications.
If pain is severe, an opioid like pethidine or tramadol can be used.
Definitive Treatment (The Ward Round Plan):
First-Line & Gold Standard: Elective Laparoscopic Cholecystectomy. This is the definitive treatment. The goal is to remove the gallbladder before a serious complication occurs.
Conservative Management (Medical): Only for patients who are unfit or refuse surgery.
Low-fat diet.
Ursodeoxycholic acid (UDCA) can be used to dissolve small, pure cholesterol stones, but it has a low success rate, takes years, and stones often recur. It is rarely used in practice here.
Long-Term & Discharge Plan (Post-Cholecystectomy):
Most patients are discharged on Day 1 post-op.
Follow-up in the Surgical Outpatient Department (SOPD) in 1-2 weeks for wound review and to discuss the histopathology report.
Advise patients that post-cholecystectomy syndrome (persistent dyspepsia, bloating) can occur, but is uncommon. Some patients may experience looser stools initially, which usually improves.
VIII. Complications
These are the reasons we operate. Complications arise from the stones, not the chronic inflammation itself.
Immediate (Can happen at any time):
Acute Cholecystitis: Management: Admission, IV antibiotics, and early laparoscopic cholecystectomy.
Choledocholithiasis & Ascending Cholangitis: Management: This is an emergency. IV antibiotics and urgent ERCP for drainage, followed by cholecystectomy later.
Gallstone Pancreatitis: Management: Supportive care, IV fluids, analgesia. ERCP may be needed if cholangitis is also present.
Long-Term:
Gallbladder Cancer: Chronic inflammation is a significant risk factor. It is rare but highly lethal. This is a key reason to remove a symptomatic gallbladder.
Mirizzi Syndrome: A large stone impacted in the cystic duct compresses the common hepatic duct, causing jaundice. Management: Requires careful surgical dissection, often an open procedure.
IX. Prognosis
Excellent after elective laparoscopic cholecystectomy. It is a curative procedure.
The risk of conversion from a laparoscopic to an open procedure is higher in chronic cholecystitis (~5-10%) compared to simple biliary colic, due to fibrosis and distorted anatomy.
Top 3 Prognostic Factors (for surgical outcome):
Presence of pre-operative complications (e.g., pancreatitis).
Patient comorbidities (cardiac, respiratory fitness for surgery).
Surgeon's experience.
X. How to Present to Your Senior
Use this format when referring from the clinic or discussing on a ward round.
"Dr., for your review, this is Puan Zainab in SOPD clinic room 2. A 45-year-old lady with a BMI of 32, presenting with a 6-month history of recurrent post-meal RUQ pain. Her LFT is normal. An ultrasound done last month confirms multiple gallstones with a thickened gallbladder wall of 4mm, suggestive of chronic cholecystitis. She is currently pain-free. My plan is to counsel her for and list her for an elective laparoscopic cholecystectomy. Would you agree?"
XI. Summary & Further Reading
Top 3 Takeaways:
Chronic cholecystitis is caused by recurrent gallstone irritation, leading to a fibrotic, dysfunctional gallbladder.
The diagnosis is made with a good history and a confirmatory ultrasound showing gallstones and a thickened wall.
The definitive treatment is elective laparoscopic cholecystectomy to prevent severe complications like acute cholecystitis, cholangitis, or pancreatitis.
Key Resources:
UpToDate: Search for "Chronic cholecystitis" and "Laparoscopic cholecystectomy". This should be your primary resource for detailed clinical questions.
StatPearls: Laparoscopic Cholecystectomy - Good for a quick, evidence-based overview of the procedure.
Malaysian National Antimicrobial Guideline (NAG): Refer to this for antibiotic choices when you suspect an acute-on-chronic presentation
