Cholecystitis and Cholelithiasis in Patients on Total Parenteral Nutrition: Systematic Evaluation of 518 Patients with Meta-Analysis

Mann, Nirmal S.
February 2013
International Medical Journal;Feb2013, Vol. 20 Issue 1, p18
Academic Journal
Objectives: Many adult patients on total parenteral nutrition (TPN) develop biliary sludge, cholelithiasis, cholecystitis and acalculous cholecystitis. To evaluate this problem we reviewed the literature and performed qualitative meta-analysis (QMA) on 518 adult patients on TPN. Methods: We did a PubMed search using the terms TPN, chlolelithiasis, cholecystitis, and biliary sludge without time or language barrier. Additional papers were manually added after evaluating the reference lists of key articles. To facilitate QMA, summary sheets of all the publications were created. QMA was performed using the well-established methods of Qualitative Research e.g. diagramming, theme repetition without serious contradiction, theme saturation and investigator reflexivity. Quantitative data can be used to perform QMA. Results: The search produced 518 adults on TPN for systematic evaluation. Information about gender was available in 276/518 (53.2%) cases. 177 (64.1%) were men and 99 (35.9%) were women. There appears to be male predominance. Information about age was available in 434/518 (83.7%) cases. The mean age was 39.5 (range 16-84) years. Information about duration of TPN was available in 339/518 (65.4%) cases. The mean duration of TPN was 406.3 days (range 7-2100). On the long term TPN about 25% of patients develop symptomatic cholecystitis; a large number develop biliary sludge. In these patients the incidence of acalculous cholecystitis is 16%. Use of anticholinergic and narcotic drugs increases the risk. Fasting during TPN leads to gallbladder stasis due to lack of hormonal stimulation. Most stones in this setting are pigment stones. Ultrasound and hepatobiliary scans are complementary in the early diagnosis especially of acalculous cholecystitis. Early cholecystotomy is the surgery of choice although some patients have been treated with cholecystectomy. An effort has been made to prevent biliary sludge by use of long-acting cholecystokinin infusion or the use of ceruletid. Conclusions: About 25% adults on prolonged TPN develop symptomatic cholelithiasis; of these 16% have acalculous cholecystitis. Early cholecystectomy is the definitive operation; some patients can be treated by cholecystotomy. The morbidity rate for elective cholecystectomy in these patients is 48%; it is 64% for emergency cholecystectomy. The operative morbidity rate for elective cholecystectomy in these patients is 11%, for emergency cholecystectomy it is 14%.


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