Chronic cholecystitis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vendhan Ramanujam M.B.B.S [2]


Chronic cholecystitis is a chronic inflammatory disease of the gallbladder with histological evidence of chronic inflammation like large range of related inflammatory epithelial changes including mononuclear infiltrate, fibrosis, thickening of muscular layer, dysplasia, hyperplasia and metaplasia.[1]


Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Chronic cholecystitis does not have life-threatening causes; however, if chronic cholecystitis is complicated by an acute process, it can be by itself life threatening.

Common Causes


Shown below are algorithms depicting the diagnostic and therapeutic approach of chronic cholecystitis according to the Society for Surgery of the Alimentary Tract (SSAT),[3] the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES),[4] the Tokyo guidelines for management of cholecystitis,[5] review of data from multiple studies on acalculous cholecystitis,[6] and American Roentgen Ray Society (ARRS).[7][8]

Characterize the symptoms:
❑ Recurrent biliary type abdominal pain with or without fever
❑ Recurrent abdominal bloating
❑ Unstable stool with constipation/diarrhea
❑ Weight loss
Examine the patient:
Murphy's sign
❑ No specific finding
Consider alternative diagnosis:
Biliary colic
Gallbladder cancer
❑ Gallbladder mucocele
Peptic ulcer disease
Order laboratory tests:
❑ Total bilirubin
❑ Direct bilirubin
Alkaline phosphatase
Order imaging studies:
CT abdomen
HIDA scan
Cholecystokinin stimulated HIDA scan
Diagnostic criteria:
❑ Chronic biliary symptoms
❑ Absence of other pain sources during CT
❑ Stone-free TAUSG
❑ Delayed gallbladder isotope accumulation, irregular gallbladder filling, or photopenic areas and septations during HIDA cholescintigraphy
❑ Low EF (<35%) in cholecystokinin stimulated HIDA scan
Confirmed chronic cholecystitis
Uncomplicated chronic cholecystitis:
❑ Elective cholecystectomy
Complicated chronic cholecystitis:
Appropriate management of complications
Acute on chronic cholecystitis
Gallbladder carcinoma
Gallstone ileus

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BMP: Basic metabolic profile; CBC: Complete blood count; CRP: C-reactive protein; CT: Computed tomography; EF: Ejection fraction; GGT: Gamma-glutamyl transpeptidase; HIDA scan: Hepatobiliary iminodiacetic acid scan; TAUSG: Transabdominal ultrasonography


  • Always consider chronic cholecystitis in the setting of cholelithiasis.
  • HIDA scan should complement TAUSG and CT scan whenever the diagnosis is uncertain as well as to differentiate it from acute from chronic cholecystitis.[9]
  • Consider prophylactic cholecystectomy in case of porcelain gallbladder because of its association with gallbladder carcinoma. It is best seen on CT scan as plaques or punctuate foci of mural calcification.
  • Although chronic cholecystitis may mimic gallbladder carcinoma, consider chronic cholecystitis in the setting of xanthogranulomatous cholecystitis when hypoattenuating mural nodules are visualized during imaging.


  • Do not delay surgical treatment in gallstone ileus because it carries a high risk of mortality rate (20–40%).[10]


  1. Zhou, D.; Guan, WB.; Wang, JD.; Zhang, Y.; Gong, W.; Quan, ZW. (2013). "A comparative study of clinicopathological features between chronic cholecystitis patients with and without Helicobacter pylori infection in gallbladder mucosa". PLoS One. 8 (7): e70265. doi:10.1371/journal.pone.0070265. PMID 23936177.
  2. Kimura, Y.; Takada, T.; Kawarada, Y.; Nimura, Y.; Hirata, K.; Sekimoto, M.; Yoshida, M.; Mayumi, T.; Wada, K. (2007). "Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg. 14 (1): 15–26. doi:10.1007/s00534-006-1152-y. PMID 17252293.
  3. Duncan, CB.; Riall, TS. (2012). "Evidence-based current surgical practice: calculous gallbladder disease". J Gastrointest Surg. 16 (11): 2011–25. doi:10.1007/s11605-012-2024-1. PMID 22986769. Unknown parameter |month= ignored (help)
  4. Overby, DW.; Apelgren, KN.; Richardson, W.; Fanelli, R.; Overby, DW.; Apelgren, KN.; Beghoff, KR.; Curcillo, P.; Awad, Z. (2010). "SAGES guidelines for the clinical application of laparoscopic biliary tract surgery". Surg Endosc. 24 (10): 2368–86. doi:10.1007/s00464-010-1268-7. PMID 20706739. Unknown parameter |month= ignored (help)
  5. Mayumi, T.; Someya, K.; Ootubo, H.; Takama, T.; Kido, T.; Kamezaki, F.; Yoshida, M.; Takada, T. (2013). "Progression of Tokyo Guidelines and Japanese Guidelines for management of acute cholangitis and cholecystitis". J UOEH. 35 (4): 249–57. PMID 24334691. Unknown parameter |month= ignored (help)
  6. Huffman, JL.; Schenker, S. (2010). "Acute acalculous cholecystitis: a review". Clin Gastroenterol Hepatol. 8 (1): 15–22. doi:10.1016/j.cgh.2009.08.034. PMID 19747982. Unknown parameter |month= ignored (help)
  7. Smith, EA.; Dillman, JR.; Elsayes, KM.; Menias, CO.; Bude, RO. (2009). "Cross-sectional imaging of acute and chronic gallbladder inflammatory disease". AJR Am J Roentgenol. 192 (1): 188–96. doi:10.2214/AJR.07.3803. PMID 19098200. Unknown parameter |month= ignored (help)
  8. O'Connor, OJ.; Maher, MM. (2011). "Imaging of cholecystitis". AJR Am J Roentgenol. 196 (4): W367–74. doi:10.2214/AJR.10.4340. PMID 21427298. Unknown parameter |month= ignored (help)
  9. DiBaise, JK.; Oleynikov, D. (2003). "Does gallbladder ejection fraction predict outcome after cholecystectomy for suspected chronic acalculous gallbladder dysfunction? A systematic review". Am J Gastroenterol. 98 (12): 2605–11. doi:10.1111/j.1572-0241.2003.08772.x. PMID 14687804. Unknown parameter |month= ignored (help)
  10. Lassandro, F.; Romano, S.; Ragozzino, A.; Rossi, G.; Valente, T.; Ferrara, I.; Romano, L.; Grassi, R. (2005). "Role of helical CT in diagnosis of gallstone ileus and related conditions". AJR Am J Roentgenol. 185 (5): 1159–65. doi:10.2214/AJR.04.1371. PMID 16247126. Unknown parameter |month= ignored (help)

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