Model Answer
0 min readIntroduction
Chronic cholecystitis, inflammation of the gallbladder over a prolonged period, frequently arises as a consequence of cholelithiasis – the presence of gallstones. These stones obstruct the cystic duct, leading to bile stasis, inflammation, and eventual gallbladder wall changes. Globally, approximately 10-15% of adults have gallstones, with a significant proportion developing chronic cholecystitis. Effective management aims to alleviate symptoms, prevent complications like acute cholecystitis, cholangitis, and gallbladder perforation, and improve the patient’s quality of life. This answer will outline the comprehensive approach to managing this common clinical scenario.
I. Diagnosis
Accurate diagnosis is crucial before initiating management. This involves:
- History & Physical Examination: Focus on symptoms like right upper quadrant pain (often postprandial), nausea, bloating, and indigestion.
- Imaging:
- Ultrasound: First-line imaging modality for detecting gallstones and gallbladder wall thickening.
- Hepatobiliary Iminodiacetic Acid (HIDA) Scan: Useful if ultrasound is inconclusive, assessing cystic duct patency.
- CT Scan: Can identify complications like perforation or abscess.
- MRCP (Magnetic Resonance Cholangiopancreatography): Provides detailed visualization of the biliary tree, useful for detecting common bile duct stones.
- Laboratory Tests: Liver function tests (LFTs) may be normal or show mild elevation. Amylase and lipase should be checked to rule out pancreatitis.
II. Conservative Management
Conservative management is considered for patients with mild, infrequent symptoms and significant comorbidities that preclude surgery.
- Dietary Modifications: Low-fat diet to reduce gallbladder stimulation.
- Ursodeoxycholic Acid (UDCA): A bile acid that can dissolve small cholesterol stones over a prolonged period (months to years). Success rates are limited, and recurrence is common after discontinuation.
- Pain Management: Analgesics (NSAIDs or paracetamol) for symptomatic relief.
- Regular Monitoring: Periodic ultrasound to monitor for disease progression or complications.
III. Surgical Management: Cholecystectomy
Cholecystectomy, surgical removal of the gallbladder, is the definitive treatment for symptomatic chronic cholecystitis with cholelithiasis.
A. Laparoscopic Cholecystectomy
This is the gold standard approach due to its minimally invasive nature, shorter hospital stay, and faster recovery.
- Procedure: Performed through small incisions using a laparoscope and specialized instruments.
- Indications: Most patients with symptomatic chronic cholecystitis.
- Complications: Bile duct injury (most serious), bleeding, infection, retained stones, postcholecystectomy syndrome.
B. Open Cholecystectomy
Reserved for cases where laparoscopic cholecystectomy is not feasible or safe.
- Indications: Severe inflammation, adhesions from previous surgery, coagulopathy, anatomical variations.
- Procedure: Involves a larger incision to access the gallbladder.
- Complications: Higher risk of wound infection, longer recovery time compared to laparoscopic cholecystectomy.
IV. Management of Complications
Prompt recognition and management of complications are essential.
- Acute Cholecystitis: Requires hospitalization, intravenous fluids, antibiotics, and urgent cholecystectomy.
- Cholangitis: Requires urgent ERCP (Endoscopic Retrograde Cholangiopancreatography) for stone extraction and antibiotics.
- Gallbladder Perforation: Requires emergency surgery and drainage.
- Postcholecystectomy Syndrome: Persistent abdominal symptoms after cholecystectomy. Management includes dietary modifications, antispasmodics, and further investigation to rule out other causes.
V. Special Considerations
Management should be tailored to individual patient factors.
- Elderly Patients: Careful assessment of comorbidities and risk-benefit ratio before surgery.
- Pregnant Women: Cholecystectomy is generally delayed until after delivery, unless there are life-threatening complications.
- Patients with Coagulopathy: Correction of coagulopathy before surgery.
Conclusion
The management of chronic cholecystitis with cholelithiasis requires a comprehensive approach, ranging from conservative measures for mild cases to definitive surgical intervention with cholecystectomy for symptomatic patients. Laparoscopic cholecystectomy remains the preferred surgical technique. Early diagnosis, prompt management of complications, and individualized treatment plans are crucial for optimizing patient outcomes and improving quality of life. Ongoing research focuses on improving stone dissolution therapies and refining surgical techniques to minimize complications.
Answer Length
This is a comprehensive model answer for learning purposes and may exceed the word limit. In the exam, always adhere to the prescribed word count.