An Uncommon Cause of Chronic
Nausea and Abdominal Pain?
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.
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.
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
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
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
Ideas ?
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
Hospital Course
Undergoes Laporascopic cholecystectomy 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
Chronic Acalculous Cholecystitis
Literature
Search of PubMed, Medline, MD Consult,
Google negative for review articles on topic.
3 most recent reviews of acute acalculous
cholecystitis, dating back to 2010, without
mention of topic.
Not addressed in UpToDate
Literature Found
“The clinical diagnosis of chronic acalculous
cholecystitis”. 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 cholecytokininstimulated scintigraphy (CCK-HIDA)
 176 cholecytectomies for biliary pain without stones,
152 pathologically verified CAC. Compared 497
cholecystectomies with stones.
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.
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
Literature
“ A long-term cohort study of outcome after
cholecystectomy for chronic acalculous
cholecystitis”. 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
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.
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
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.
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%.
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.
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.