An Uncommon Cause of Chronic Nausea and Abdominal Pain?

1. An Uncommon Cause of Chronic Nausea and Abdominal Pain?

2. Patient Presentation • 89 F presents with acute onset 1 day duration vomiting, exacerbation of chronic nausea and diffuse abdominal pain. • No associated hematemesis, hematochezia, diarrhea, constipation, fever, chills, pulmonary, cardiac or urinary symptoms. No family member with such symptoms. Patient attributing symptoms to an unusually rich supper preceding onset.

3. Pertinent PMHX • 5 year hx slowly progressive, persistent nausea, diffuse gnawing abdominal pain associated with marked weight loss. • Unique characteristic: pain and nausea most notable in morning, dissipating by noon initially, but last 1.5 year lasting into early evening. • S/P extensive evaluation, including 3 independent GI consults with endoscopies, without diagnosis. Empiric treatment depression, anxiety nonhelpful. PCP recommending hospice care March 2011.

4. Other Past Medical History • HTN, controlled • MVR from rheumatic heart disease with normal systolic/diastolic fxn • severe osteoporosis with marked kyphosis • chronic pain from spinal degeneration on chronic oral narcotics • Past hx episode P Afib x3 with admits for pelvic fracture, urosepsis, and surgery. Subsequent evals with NSR, pt declining anticoagulation. • Mild dementia, noticed by family last 2 years, worsened when patient acutely ill • TAH/BSO greater 40 yrs ago for menorrhagia, benign

5. Medicines Vicoden 15mg QID Metoprolol 25 BID HCTZ 25 on Mon, Wed, Friday Effexor XR 37.5 HS Calcium 1250 BID Vitamin D 2000 QD Citrucel 1 scoop BID Miralax QD Ambien 5 mg HS

6. Initial ED evaluation/data Vital signs: T 38.1 P 110 BP 148/86 O2 RA 93% Exam abnormalities: A & O x4, dry oral mucosa, severe kyphosis, 3/6 systolic murmur Pertinent normal exam: lungs clear, abdomen NT, ND,soft, normal BS, no guarding, no rebound, heme negative rectal Lab/test: WBC 12.2, lactate 4.0, sodium 134 remaining Chem 7, LFT, lipase, CBC, UA, Abd CT all normal

7. Ideas ?

8. Subsequent Evaluation Hospitalist evaluation: notes hx of rich meal preceding onset vomiting, his hx obtaining some focalization of abdominal pain to RUQ. Orders Abd U/S: normal Orders HIDA scan: abnormal, no GB visualization 1 hour Calls general surgery consult

9. Hospital Course Undergoes Laporascopiccholecystectomy without complication Surgeon reporting GB appearing inflamed, not purulent nor necrotic; noting GB anteriorly located. Pathology report diagnosing changes consistent with chronic cholecystitis Patient with dramatic though not 100% resolution nausea, pain. Complete resolution vomiting, low grade fever, lactic acidosis, leucocytosis. Family noting patient eating more with each meal than has in 5 years

10. Chronic Acalculous Cholecystitis

11. Literature Search of PubMed, Medline, MD Consult, Google negative for review articles on topic. 3 most recent reviews of acute acalculouscholecystitis, dating back to 2010, without mention of topic. Not addressed in UpToDate

12. Literature Found “The clinical diagnosis of chronic acalculouscholecystitis”. Surgery 2001;130:578-83. Peter F.M. Chen MD, Cleveland Clinic Health System • First prospective study • Study subjects: chronic biliary symptoms with normal abdominal ultrasound. Further studied with EGD, multidiscipline evaluations, and cholecytokinin-stimulated scintigraphy (CCK-HIDA) • 176 cholecytectomies for biliary pain without stones, 152 pathologically verified CAC. Compared 497 cholecystectomies with stones.

13. Conclusion of this study The syndrome consisting of chronic biliary symptoms, stone-free sonograms, low EF in CCK-HIDA, and absence of other pain sources is highly predictive for CAC, which is well treated with LC, with results similar to those for calculous disease.

14. Critique of article Mostly focused on use of CCK-HIDA, inconsistency with definition of abnormal ejection fraction and fact not clear how many of the stone free biliary pain cholecystectomies had a normal CCK-HIDA

15. Literature “ A long-term cohort study of outcome after cholecystectomy for chronic acalculouscholecystitis”. The American Journal of Surgery 2003; 185: 91-95. Sanjay Jagannath MD. The Johns Hopkins Hospital • First study to address long term outcomes • Retrospective study of patients with biliary-type pain and pathologically proven CAC • 19 CAC with matched 19 CCC

16. Conclusion There was no difference in outcome between the groups after an average follow-up of 8.37 years. Postcholecystectomy patients with chronic sholecystitis and no gallstones have long-term, complete pain resolution, similar to patients with gallstones.

17. Literature “Laparoscopic cholecystectomy for symptoms of biliary colic in the absence of gallstones”. The American Journal of Surgery. 2003; 186:1-3. Daniel Brosseuk MD. Cariboo Memorial Hospital, Canada • Premise of study was that careful evaluation of clinical presentation is adequate to allow accurate dianosis without reliance on ancillary tests. • Retrospective chart review • 88 patients • 93% satisfied with outcome 25 months, phone survey

18. Conclusion Acalculous cholecystitis is an entity that can be satisfactorily diagnosed by detailed history and physical examination with high patient satisfaction achieved after surgical management.

19. Imaging Studies for CAC, the Literature “A Systematic Review and Meta-Analysis of Diagnostic Performance of Imaging in Acute Cholecystitis”. Radiology. 2012; 264: 708-720. Jordy J.S. Kiewiet MD. • Included 57 studies dating from 1978 to 2010 • Did not differentiate specific type of scintography • Concluded scintography most specific/sensitive(90 and 96%) • Noted US still first-tier test given ease of use, low cost, no radiation but noted lower sensitivity/specificity of 81 and 83%.

20. More Literature “Hepatobiliary Scintigraphy in Acute Cholecystitis”. Seminars in Nuclear Medicine. 2012; 42: 84-100. Mark Tulchinsky MD. Pennsylvania State University. • Reviewed all literature from the inception of hepatobiliary scintigraphy which was 1975. • Did review specific types, ie CCK-stimulated and MA-HIDA. • Concluded most accurate test is the Morphine-augmented HIDA with pooled sensitivity 96% and specificity of 89%. • For same reasons as in prior study, noted US still most practical first-tier study.

21. Summary • Since mid 1990s, chronic acalculous cholecystitis is considered an entity, not considered controversial. • There is no consensus agreed upon clinical criteria for diagnosis nor for standardized evaluation. • Review of literature suggesting patients with biliary type symptoms, including RUQ discomfort, dyspepsia, nausea, bloating, with normal abdominal ultrasound do benefit from laparoscopic cholecystectomy. • If imaging study desired to evaluate for this diagnosis, literature indicating a morphine augmented HIDA scan most accurate test.