Pain patterns after distension of the gallbladder in patients with acute cholecystitis

The Symptomatic Outcomes of Cholecystectomy for Gallstones

Cholecystectomy is the definite treatment for symptomatic gallstones, and rates are rapidly rising. Symptomatic complicated gallstones are generally treated with cholecystectomy, but there is no consensus on the clinical selection of patients with symptomatic uncomplicated gallstones for cholecystectomy. The aim of this review is to describe symptomatic outcomes before versus after cholecystectomy in patients with symptomatic gallstones as reported in prospective clinical studies and to discuss patient selection for cholecystectomy. Following cholecystectomy, resolution of biliary pain is high and reported for 66-100%. Dyspepsia has an intermediate resolution of 41-91% and may co-exist with biliary pain but may also develop following cholecystectomy with an increase of 150%. Diarrhea has a high increase and debuts in 14-17%. Persisting symptoms are mainly determined by preoperative dyspepsia, functional disorders, atypical pain locations, longer duration of symptoms, and poor psychological or physical health. Patient satisfaction following cholecystectomy is high and may reflect symptom alleviation or a change in symptoms. Comparison of symptomatic outcomes in available prospective clinical studies is limited by variations in preoperative symptoms, clinical presentations, and clinical management of post-cholecystectomy symptoms. When selecting patients with biliary pain only in a randomized controlled trial, 30-40% still have persisting pain. Strategies for the selection of patients with symptomatic uncomplicated gallstones based on symptoms alone are exhausted. For the development of a selection strategy, future studies should explore the impact of objective determinants for symptomatic gallstones on pain relief following cholecystectomy.

Acute Acalculous Cholecystitis: Think of Hepatitis A Infection and Do Not Underestimate Pain

ABSTRACT

A 14-year-old adolescent girl presented with severe abdominal pain, tenderness, and guarding in the right upper quadrant associated with nonbilious vomiting, scleral icterus, and fever. Laboratory tests were consistent with acute hepatitis A virus-related cholestatic hepatitis. A point-of-care ultrasound showed mild gallbladder wall thickening with increased color Doppler flow and pericholecystic fluid collection, in the absence of gallstones or biliary ducts dilatation, thus suggesting acute acalculous cholecystitis. Both the clinical symptoms and the point-of-care ultrasound findings completely resolved within 1 week after admission with conservative treatment.

Determinants for symptomatic gallstone disease readmissions - results from a cohort with screen-detected gallstone disease

AIM OF THE STUDY

Selection of patients for cholecystectomy is hampered by lack of objective criteria. The objectives of this cohort study were to identify if patient, symptoms, or gallstone disease characteristics determined readmission in an unselected cohort with screen-detected gallstone disease and who had experienced a first admission with symptomatic gallstone disease.

METHODS

Data from three random sampled population-based cohorts were used. At baseline, participants were screened with ultrasound and 664 had gallstones of which 84 had a first admission without cholecystectomy performed. A cohort study was performed with follow-up up for hospital readmissions beyond 30 days through central registers. Age adjusted Cox regression analyses were performed.

RESULTS

Readmissions occurred in 60.8% and cholecystectomy was eventually performed in 47.7% of patients. Early readmissions were determined by abdominal pain in the epigastrium (Hazard ratio (HR) 3.63, 95% confidence interval (CI) [1.62;8.12]) and of moderate intensity (HR 2.71, 95% CI [1.20;6.16]). Late readmissions were determined by larger gallstone size, especially when above 10mm (HR 4.11, 95% CI [1.18;14.3]) and inversely determined by age (HR 0.97, 95% CI [0.95;0.998]). In patients with initially uncomplicated gallstone disease, cholecystectomy was inversely determined by age (HR 0.96, 95% CI [0.93;0.98]).

CONCLUSION

Once gallstones have become symptomatic and caused hospital admission, a persisting high risk for future readmission exists and half of patients end up having cholecystectomy. Pain in the epigastrium, larger gallstones, and younger age determine readmission. These determinants should be tested in future clinical treatment algorithms for gallstone disease.

Quality of Life and Pain in Patients with Acute Cholecystitis

Background:

Acute cholecystitis carries a higher risk of subsequent gallstone related events than symptomatic, non-complicated disease. However, it is largely unknown to what extent non-operative treatment will affect the patient's well-being as no trial has studied the possible consequences on pain and quality of life. Our aim was to study in a randomized trial how observational treatment (watchful waiting) compared to cholecystectomy.

Methods:

Sixty-four patients with acute cholecystitis were randomized to observation or cholecystectomy. All gallstone related events were registered and patients answered questionnaires on quality of life (PGWB and NHP) and pain (Pain score and VAPS) at randomization and at 6, 12 and 60 months later.

Results:

Patients were followed-up for a median of 67 months. Ten of 33 patients (30 %, 95 % CI 15 %−46 %) patients randomized to observation and 27 of 31 (87 %, 95 % CI 75 %−99 %) of patients randomized to operation had a cholecystectomy. Twelve of 33 (36 %, 95 % CI 20 %−53 %) patients in the observation group had a gallstone related event compared to 6 of 31 (19 %, 95 % CI 5%−33 %) patients in the operation group, but the difference was not significant. When patients were grouped according to randomization or actual operative outcome (+/− cholecystectomy), we did not find any significant differences in pain or quality of life measurements.

Conclusion:

Although conservative treatment of AC carried a certain but not significantly increased risk of subsequent gallstone related events, this did not influence the symptomatic outcome as assessed by quality of life and pain measurements. Thus, we argue that conservative (non-operative) treatment and observation of AC is an acceptable option and should at least be considered in elderly and frail patients.

A Quasi-Nonlinear Analysis of the Anisotropic Behaviour of Human Gallbladder Wall

Estimation of biomechanical parameters of soft tissues from noninvasive measurements has clinical significance in patient-specific modeling and disease diagnosis. In this work, we present a quasi-nonlinear method that is used to estimate the elastic moduli of the human gallbladder wall. A forward approach based on a transversely isotropic membrane material model is used, and an inverse iteration is carried out to determine the elastic moduli in the circumferential and longitudinal directions between two successive ultrasound images of gallbladder. The results demonstrate that the human gallbladder behaves in an anisotropic manner, and constitutive models need to incorporate this. The estimated moduli are also nonlinear and patient dependent. Importantly, the peak stress predicted here differs from the earlier estimate from linear membrane theory. As the peak stress inside the gallbladder wall has been found to strongly correlate with acalculous gallbladder pain, reliable mechanical modeling for gallbladder tissue is crucial if this information is to be used in clinical diagnosis.

Mandatory and optional function tests for biliary disorders

Function tests in gastroenterology and hepatology aim to provide criteria for diagnosis of specific disorders and for prediction of patient responses to therapy. This review focuses on the utility of function tests in the management of gallstone disease and functional biliary disorders. In gallstone disease, function tests may be considered in the selection of candidates for nonsurgical therapy of gallbladder stones only. In cases of suspected functional biliary disorders, experts have advocated the use of classical noninvasive tests such as hepatobiliary scintigraphy. However, unequivocal evidence for their utility in diagnosis or patient selection for invasive treatment is yet to be provided. Recently, more advanced noninvasive tests such as real-time ultrasonography or secretin-stimulated magnetic resonance cholangiopancreaticography have been described. Controlled trials using these novel techniques may provide a rationale for the use of function tests in clinical management of calculous and acalculous biliary diseases, but are currently not available.

Association between gallstone-evoked pain, inflammation and proliferation of nerves in the gallbladder: a possible explanation for clinical differences

OBJECTIVE

To investigate whether enhanced neuroproliferation could be involved in the pathogenesis of gallstone pain.

MATERIAL AND METHODS

Gallbladders from 117 patients with gallstones and 43 controls were examined. The gallbladder samples were immunostained against the pan-neuronal marker PGP 9.5 and the number of nerves and nerve area per tissue area estimated.

RESULTS

More nerves and an increased nerve area per tissue area were found in uncomplicated symptomatic gallstone disease. In comparison, acute cholecystitis displayed a significantly (p=0.01) decreased number of nerves and nerve area per tissue area. In both categories, the gallbladder neck contained more nerves (p=0.06 and 0.04, respectively) and an increased nerve area per tissue area (p=0.034 and 0.008, respectively) than the body.

CONCLUSIONS

Uncomplicated disease showed enhanced neuroproliferation, significantly more in the gallbladder neck, whereas significantly fewer nerves were observed in acute cholecystitis. Nerve growth alteration may play a role in uncomplicated gallstone pain but the pathology may be different in inflammation.

On the mechanical behavior of the human biliary system

This paper reviews the progress made in understanding the mechanical behaviour of the biliary system. Gallstones and diseases of the biliary tract affect more than 10% of the adult population. The complications of gallstones, i.e. acute pancreatitis and obstructive jandice, can be lethal, and patients with acalculous gallbladder pain often pose diagnostic difficulties and undergo repeated ultrasound scans and oral cholecystograms. Moreover, surgery to remove the gallbladder in these patients, in an attempt to relieve the symptoms, gives variable results. Extensive research has been carried out to understand the physiological and pathological functions of the biliary system, but the mechanism of the pathogenesis of gallstones and pain production still remain poorly understood. It is believed that the mechanical factors play an essential role in the mechanisms of the gallstone formation and biliary diseases. However, despite the extensive literature in clinical studies, only limited work has been carried out to study the biliary system from the mechanical point of view. In this paper, we discuss the state of art knowledge of the fluid dynamics of bile flow in the biliary tract, the solid mechanics of the gallbladder and bile ducts, recent mathematical and numerical modelling of the system, and finally the future challenges in the area.

The influence of gallbladder function on the symptomatology in gallstone patients, and the outcome after cholecystectomy or expectancy

The purpose of this study was to examine whether gallbladder function as assessed by a hepatobiliary scintigraphy was related to the symptomatology in gallstone patients and to the outcome 1 year after either cholecystectomy or watchful waiting. The study included 100 patients with uncomplicated gallstone disease. Fifty-six patients had a functioning gallbladder and 44 had a nonfunctioning gallbladder. Patients with a nonfunctioning gallbladder had significantly more vomiting and received more pain-killing injections during pain attacks. Otherwise, there were no differences in pain patterns or characteristics of dyspeptic symptoms in relation to gallbladder function. In patients with a functioning gallbladder, there were no significant differences between the group of patients with impaired and normal gallbladder function. Cholecystectomy was performed in 69 patients and at the 1-year follow-up; 22% continued to have pain attacks, but this was not related to the gallbladder function preoperatively. In 31 patients without cholecystectomy, 14 patients became asymptomatic within a 1-year follow-up. However, this was not related to gallbladder function. In conclusion, gallbladder function evaluated by a hepatobiliary scintigraphy was not related to the symptoms in gallstone patients, and was not related to the occurrence of symptoms after cholecystectomy or watchful waiting.

Somatosensory changes in the referred pain area in patients with cholecystolithiasis

BACKGROUND AND AIMS

Patients with abdominal pain provoked by acute cholecystitis increase the somatic sensitivity in the referred somatic pain area. Our aim in the present paper was to examine somatosensory changes in the referred pain area (previously evoked by painful attacks) in patients with uncomplicated gallstone disease and to evaluate the possible relation between referred pain patterns and clinical findings. Somatosensory changes in these areas may be important in the persistent pain after treatment and may help to develop treatment strategies for abdominal pain in the post-cholecystectomy syndrome.

SUBJECTS

Forty-two patients with symptomatic cholecystolithiasis, confirmed ultrasonographically, were studied in the pain-free period.

METHODS

Sensitivity and pain thresholds for standardized experimental sensory testing including different modalities: pinprick, pinching, heat, cold, pressure, and single and repeated electrical stimulation were studied in the area where the pain was referred to during the acute attacks, and in a control area on the contralateral side of the abdomen.

RESULTS

Patients with verified cholecystolithiasis showed hyperalgesia to pinprick (26% of subjects, P < 0.05) and cold stimuli (21% of subjects, P < 0.05) in the referred pain area. There was also a significant reduction in sensation/pain thresholds (indicating hyperalgesia) in the referred pain area to single (P = 0.007/P = 0.002) and repeated electrical (P = 0.017/P = 0.043) stimuli, as well as in pain threshold to pinching and mechanical stimuli (P = 0.049/P < 0.001). There were no significant relations between the hyperalgesia and the clinical findings.

CONCLUSION

Cholecystolithiasis leads to significant hyperalgesia in the somatic area, where pain was referred to during the acute attacks. This is explained by viscero-somatic convergence mechanisms in the central nervous system. Therefore, central neuroplastic changes may be significant in diseases related to the gallbladder such as the post-cholecystectomy syndrome.

Painful cystic duct remnant diagnosed by endoscopic ultrasound

Postcholecystectomy pain may remain unexplained and difficult to treat. This report describes three patients with constant postcholecystectomy abdominal pain that may have arisen from the cystic duct remnant or a neuroma of the cystic duct stump. In each case pain was exacerbated by pushing on cystic duct surgical clips with an EUS-guided needle, and temporarily abolished by an EUS-guided injection of bupivicaine and triamcinolone. Two patients underwent surgical resection of the cystic duct remnant and the third did not require further treatment. Two of the three patients had long-term improvement. EUS is a novel modality for assessing the cystic duct remnant and performing a therapeutic trial.