Chronic Cholecystitis
 

Chronic Cholecystitis

Chronic cholecystitis is a very common diagnosis leading to a visit to a primary care physician or gastroenterologist. It affects woman more than man, commonly in obese patients above the age of 40. Chronic intermittent right upper quadrant abdominal pain, nausea following fatty meals, episodic epigastric discomfort, and unintentional weight loss are usual symptoms of chronic cholecystitis. Imaging such as abdominal ultrasound and nuclear medicine scan (HIDA scan) to measure the contractility of the gallbladder are sometimes necessary to confirm the diagnosis.

Most patients with chronic cholecystitis were found to have gallstones within the gallbladder.
In many patients, gallstones are easily found on imaging, especially with the ultrasound. This is the most sensitive test to find gallstones. The liver function test is usually normal and the patients do not have jaundice. It is important to obtain a complete history and physical examination to rule out other potential causes of pain, such as peptic ulcer disease, gastritis, duodenitis, or even right-sided colon infection. When other causes of pain are suspected, a diagnostic EGD (upper endoscopy) is helpful to confirm the diagnosis. A subset of benign gallbladder disease called biliary dyskinesia is diagnosed when the ejection fraction of the gallbladder falls less than 35% on HIDA scan. This means, the gallbladder has an inadequate/poor emptying which leads to bile stasis, pain, and subclinical gallbladder inflammation.

Once the diagnosis of chronic cholecystitis is confirmed, gallbladder removal surgery is indicated. Laparoscopic cholecystectomy has become the standard treatment for this disease since early 1990s. Laparoscopic cholecystectomy is one of the most common operations undertaken in United States. The resected gallbladder specimen was removed and sent to pathology for a histological examination to rule out an incidental finding of gallbladder cancer. It is our routine practice to examine the gallbladder specimen at the back table prior to sending the specimen to pathology.

It is crucial to see an experienced general surgeon or a liver surgeon to minimize potential risk of complications during laparoscopic cholecystectomy. Extrahepatic biliary duct anatomy can be anomalous and this needs to be recognized by the operating surgeon during the operation. Aberrant biliary ducts may be present and they can be easily injured when not identified. An intraoperative imaging using contrast dye injection into the biliary tree (cholangiogram) may be necessary to identify and confirm biliary duct anatomy. In experienced hands, bile leak or bile duct injury occurs in less than 1%. In rare circumstance when this occurs, immediate consultation with a liver surgeon or liver specialist is necessary. An abdominal drain is rarely necessary during an uncomplicated gallbladder removal surgery.

Majority of the laparoscopic cholecystectomy is undertaken via four small incisions. This is the conventional multiport laparoscopic cholecystectomy technique. Dr. Iswanto Sucandy and his team offer laparoscopic cholecystectomy through a single incision in the umbilicus, which creates less traumatic insults to the body and leads to a superior cosmesis result. Dr. Iswanto Sucandy is one of the few that offers this approach in the country. Our laparoscopic single site cholecystectomy is done as an outpatient procedure. The patients have the option to undergo this operation with epidural anesthesia (without general anesthesia) to achieve longer pain control postoperatively. We work with our anesthesiologist under a strict protocol to achieve this goal.

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