Clinical Practice Guideline For Cholecystitis

Description of Cholecystitis

The report is developed with an aim to evaluate the clinical practice guideline for Cholecystitis health problem. The report discusses the use of the guideline in the clinical practice. The health problem is discussed in detail and the medical management is recommended for it. The report discusses morbidity, mortality, pathophysiology, and epidemiology in relation to Cholecystitis. The effectiveness of clinical practice guideline is also discussed in the report.

The inflammation in the gallbladder which occurs due to lodging of gallstone at the gallbladder opening is known as Cholecystitis. It can lead to pain, fever, nausea, and some sever complications. The junction of gallbladder-cyst duct is obstructed with the gallstone resulting in the inflammation and severe pain. Only in limited cases the inflammation occurs without the formation of gallstones. Due to obstruction of common bile duct, diseases like jaundice, biliary colic, and light colored stool can be caused. The pancreatic duct when obstructed can produce pancreatitis, vomiting, nausea, and pain in the upper abdomen. The major reason of cholecystitis is gallbladder sludge due to which gallstones are formed (Brunicardi, et al., 2014).

The risk factors associated with cholecystitis include pregnancy, rapid weight loss, gallstones, obesity, trauma or surgery, stickle cell anemia and parenteral alimentation for prolonged time period. The patients of cholecystitis are usually ill-appearing, tachycardic and febrile. Murphy’s sign also appears in the cholecystitis patients which mean that patient feels inspiratory arrest along with deep palpation of upper right quadrant. The attack is followed by meal containing high amount of fat in it within one to six hours. The cholecystitis patient usually lies still due to the presence of peritoneal inflammation and it becomes worse with the movement (Symins and Seller, 2017).

A differential diagnosis is a list of disorders which could be the possible cause of symptoms that appears in the person. The list of differential diagnosis for cholecystitis includes peptic ulcer disease, cardiac disease, pancreatitis, hepatitis, bowel obstruction, and appendicitis. The intolerance of fatty food which produces excess accumulation of air in the esophagus after few minutes of eating is not a typical disease of gallbladder.

The different types of diagnosis which are available for cholecystitis are ultrasound, HIDA, MRCP, and ERCP. Gallstones presence, thickening of gallbladder walls and enlargement is demonstrated through ultrasound. If in case the ultrasound report is negative but the patient shows symptoms of cholecystitis then it can be visualized by HIDA. Likewise, Magnetic Resonance Cholangiopancreatography (MRCP) is a form of MRI is helpful in providing detailed images of pancreatic systems and hepatobiliary (Lee and Lee, 2014). Endoscopic retrograde Cholangiopancreatography (ECP) is a useful technique for diagnosing pancreatic and biliary ducts to detect stones in common bile ducts. ERCP is usually performed after MRCP for choledocholithiasis.

Morbidity and mortality

Cholecystitis is common in the age between 50 to 70 years and increases with BMI and age. It occurs twice in female population as compared to male population and is commonly observed in Native Americans. The overall rate of mortality for a single acute cholecystitis is 3 percent approximately (Cao, Eslick, and Cox, 2015). In young population, the rate of mortality is less than 1 percent but in patients with high risk factors and severe complications the mortality rate approaches to 10 percent.

Different medicines can be prescribed on the basis of the class of cholecystitis in order to control it. The different classes and drug prescription are discussed below:

Under this, the noncalcified and radiolucent gallstones less than 20mm in diameter are dissolved for patients who do not want cholecystectomy or can be at risk in the process of cholecystectomy. Firstly, Actigall capsule of 300 mg can be prescribed to the patient twice daily. The medication is for pregnancy category B and not for radio-opaque, radiolucent or calcified bile pigment stones. Sonogram shall be obtained at 6 and 12 months. Once the stones are completely dissolved sonogram shall be repeated between 1 to 3 months and then discontinued (Van der Louw, et al., 2016). The medicine is effective for prevention of formation of gallstones in patients suffering from rapid weight loss. The liver enzymes shall also be measured at first, third, and sixth month while taking the medicine.

Secondly, Urso forte tablet of 250mg can be prescribed to adults with pregnancy category B. The tablet is to be taken along with food. The absorption with aluminum containing antacids and bile acid sequestrants is reduced. It is advised that sonogram shall be obtained at 6 and 12 months. Once the stones are completely dissolved, the sonogram shall be repeated after 1 to 3 months and then discontinued. The medicine is effective in prevention of gall stones formation in patients suffering from rapid loss of weight. The liver enzymes shall also be measured at first, third, and sixth month while taking the medicine.

Antiemetic are drugs which are used for the treatment of different causes of vomiting and nausea (Matthews, Haas, O’Mathuna, and Dowswell, 2015). The action mechanism is not known but works in medulla oblongata for conveying the emetic impulses to vomiting center. Firstly, promethazine tablet of 12.5-25 mg/kg at the interval of 4-6 hours can be prescribed to adults and 0.5mg/kg at the interval of 4-6 hours can be prescribed to children below 2 years of age. Fatal respiratory depression can be caused in children therefore the prescription shall not be overdosed. The medication is used for patients with risk factor of pregnancy category C. Cautious use is advised for a dehydrated patient. Secondly, phenergan tablet of 12.5mg, 25mg, and 50mg can be prescribed to the patients. The use of this tablet is cautious for patients with sleep apnea, lower respiratory disorders, asthma, seizure disorders, urinary obstruction, and glaucorna. If the dosage is given intramuscularly then it may cause central nervous system depression.

Epidemiology

Firstly, ondansetron of 8 mg in the interval of 8 hours and 4mg for children between 4-11 years in the interval of 4 hours can be prescribed. Secondly, zofran tablet of 4mg/5ml for oral intake and 2mg/ml for injection can be prescribed. These medications are helpful in the prevention of vomiting and nausea. These tablets shall not be recommended to children below 4 years of age as well as neurovascular associated with chemotherapy.

Pathophysiplogy is the medical discipline which focuses on the symptoms and functions of diseased organs for the purpose of patient care and diagnosis. The pathophysiology for cholecystitis includes:

• Gallbladder empyema in which the bacteria invades in the gallbladder.
• Emphycematous cholecystitis in which infection is caused due to gas-forming bacteria.
• Perforation which requires aggressive replacement of fluid, antibiotics, and surgical exploration in emergency.
• Cholecystenteric fistula in which gallbladder is perforated into colon or duodenum and treated as obstruction in bowel with nasogastric suction, fluid replacement, and surgical exploration (Chelala, Adam, Rizk, and Makhoul, 2017).

Outpatient treatment shall be referred in case the symptoms are mild and surgeon in case the biliary colic exceeds 6 hours, intractable pain, and toxic appearing. The stones may also occur again in bile ducts post cholecysteomy.

• The health problem is adequately addressed in the clinical practice guideline. The rationale behind this saying is that guideline entails all aspects which are associated with the problem of the cholecystitis. It describes the problem in detailed manner by explaining the cause behind the problem. The guidelines provide the incidences where the problem occurs mostly. Symptoms are an important part of diagnosis of any disease which enables the care provider to understand the problem of the patient in depth and this guideline also provides the details of the symptoms related to the cholecystitis. The guidelines entails the risk factors associated with the disease and also provides detailed information of the diagnosis such as ultrasound, HIDA, MRCP, and ERCP which can be used for indentifying the disease. The guideline further illustrated the different classes of the disease and medication which can be prescribed to prevent from the complications of the disease. The amounts of dosages are also explained in the guideline and the dos and don’ts associated with the intake of the medicine are also described in detail. The guideline further explains the referral if the acuteness of the disease becomes high (Pane, Miller, and Burdon, 2017). The guideline therefore covers all these essential aspects which make it a comprehensive guideline that adequately addresses the health problem.
• The practice guideline is based on the recent evidence from the past five years only. The rate of morbidity which depict that the female population is suffering from the disease is twice more than the male population and the disease is common in Native America are the evidences which are from the past five years only. The strength of the evidence is moderate as the rate of morbidity and mortality keeps on changing every year with the advancement of technology in the medical industry. However, the evidence are useful in comparing the present figures with the past figures and analyze whether there is an increment or decrement in the number of cholecystitis patients (Morris, Guruswamy, Sheringham, and Davisdon, 2015).
• Yes the clinical practice guideline definitely provides adequate direction to the management of the health care provider for patient with the cholecystitis problem. The care provider would be able to identify whether the patient is actually suffering form cholecystitis or not by matching the symptoms of the patients with tones that are mentioned in the guideline. The guideline also suggests the referral for the patients. The condition for outpatient or surgery is mentioned in the guideline on the basis on which the management can decide whether the patient shall be treated as an outpatient or they undergo surgery for the patient. The medication prescriptions are also provided in the report which can be used by the management to suggest medicine to the patients on the basis of matching characteristics with the disease (Biankin, Piantadosi, Hollingswoth, 2015).  
• The clinical practice guideline is effective only in terms of analyzing the symptoms of the patients for cholecystitis and prescribing medicine to them. The procedure for diagnosing the disease is also mentioned in the guideline. The guideline does not cover the details of the treatment if the process has to be surgical. It lacks the information on the latest treatment such as lacroscopy which can be used to cure the disease. The mortality rate of patients with cholecystitis is decresing but the population of USA is turning aged. Also there is a risk of open cholecystectomy with the patients of old age. Therefore, lacroscopy is much more preferable. The guideline lacks details of the lacroscopy process for curing cholecystitis.
• Yes the guideline needs a revision because the curing methods mentioned in the guidelines are only limited to medication. Cholecystitis is a disease which cannot be cured only on the basis of medication (Aljasem, Abbas, Suliman, Khaddam, Al Khaddour, 2016). In cases where the pain is acute, surgical procedure is required such as open cholecystectomy and lacroscopy. The details of these methods are not mentioned in the clinical practice guidance.
• On revision, the guideline shall include latest technologies which shall be used in the prevention of Cholecystitis. By looking at increasing old age patients, lacroscopy is a much suitable cure for the Cholecystitis and it also takes less time for the recovery. Moreover, the problem of gall stones is very common in the American population. Approximately 20 million population of USA is suffering from the problem of gall stones. The major cause behind the formation of gall stones is the high intake of cholesterol and intolerance of fatty food. Therefore, the guideline shall also include the use of lacroscopy and diet tips for curing the gall stones. The changes will be evident from the analysis of the progress in total cases cured through lacroscopy. Proper value measurement will also be significant for evidencing the effectiveness of changes and improving the guideline for clinical practice. Demographic changes are one of the critical issues of current time. With the aging population, the system of healthcare in the country will have to face significant challenges for meeting the needs of the aging population. In USA, the number of people above the age of 60 years will grow by double number estimating from 50 million to 100 million by the year 2060. The time period of recovery for Cholecystitis through open cholecystectomy is relatively higher than lacroscopy and moreover it requires removal of organ so open cholecystectomy is not a safe solution for aged population. Therefore there is a need to add larcoscopy in the clinical practice guideline.
   
• Trustworthy guidelines for clinical practice require a systematic review for the selection of evidence which is available and rigorous evaluation of decision through which the evidence can be transformed into decision (Moher, et al., 2015). The likelihood of the guideline will be increased by forming it on the basis of evidence and determining its strength. The quality of the guideline will also be evaluated and its implementation shall be implemented from the perspective of systems of health care. The guideline will also be prepared by looking at the future needs and limitations.

There are few learning points based on the analysis of this case and are as follows:

• Cholecystitis is a disease of gallstones which leads to acute pain and caused due to over intake of cholesterol and intolerance to fatty food.
• There are two types of surgical methods available for curing Cholecystitis i.e. open cholecystectomy and lacroscopy out of which lacroscopy is more preferable as the organ is not removed and it takes less time for recovery (Okamoto, et al., 2018).
• The clinical practice guidelines for acute disease shall be prepared by evaluating future needs of the patients and shall be revised timely.

References

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Biankin, A.V., Piantadosi, S. and Hollingsworth, S.J. (2015). Patient-centric trials for therapeutic development in precision oncology. Nature, 526(7573), p.361.

Brunicardi, F., Andersen, D., Billiar, T., Dunn, D., Hunter, J., Matthews, J. and Pollock, R., (2014). Schwartz’s principles of surgery, 10e. UK: McGraw-hill.

Cao, A.M., Eslick, G.D. and Cox, M.R. (2015). Early cholecystectomy is superior to delayed cholecystectomy for acute cholecystitis: a meta-analysis. Journal of Gastrointestinal Surgery, 19(5), 848-857.

Chelala, E., Adam, E., Rizk, A. and Makhoul, E. (2017). Conservative management of an unusual bilioduodenal fistula post laparoscopic Duodeno-Ileal Switch (SADI-S) case report. International journal of surgery case reports, 34, pp.1-3.

Lee, E.S. and Lee, J.M. (2014). Imaging diagnosis of pancreatic cancer: a state-of-the-art review. World journal of gastroenterology: WJG, 20(24), 7864.

Matthews, A., Haas, D.M., O’Mathúna, D.P. and Dowswell, T. (2015). Interventions for nausea and vomiting in early pregnancy. Cochrane Database of Systematic Reviews, (9).

Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P. and Stewart, L.A. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews, 4(1), 1.

Morris, S., Gurusamy, K.S., Sheringham, J. and Davidson, B.R. (2015). Cost-effectiveness analysis of endoscopic ultrasound versus magnetic resonance cholangiopancreatography in patients with suspected common bile duct stones. PLoS One, 10(3), p.e0121699.

Okamoto, K., Suzuki, K., Takada, T., Strasberg, S.M., Asbun, H.J., Endo, I., Iwashita, Y., Hibi, T., Pitt, H.A., Umezawa, A. and Asai, K. (2018). Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. Journal of Hepato?biliary?pancreatic Sciences, 25(1), 55-72.

Pane, A., Miller, N.R. and Burdon, M. (2017). The Neuro-Ophthalmology Survival Guide E-Book. USA: Elsevier Health Sciences.

Symons, A.B. and Seller, R.H. (2017). Differential Diagnosis of Common Complaints E-Book. USA: Elsevier Health Sciences.

van der Louw, E., van den Hurk, D., Neal, E., Leiendecker, B., Fitzsimmon, G., Dority, L., Thompson, L., Marchió, M., Dudzi?ska, M., Dressler, A. and Klepper, J. (2016). Ketogenic diet guidelines for infants with refractory epilepsy. european journal of paediatric neurology, 20(6), 798-809.