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Chronic Cholecystitis


Cholelithiasis and cholecystitis are classified into three types based on presentation: (1) silent gallstones, in which gallstones are detected accidentally and are truly asymptomatic; (2) symptomatic gallstone disease; and (3) abdominal symptoms mimicking cholelithiasis but caused by a comorbid condition such as peptic ulcer or irritable bowel syndrome.

Asymptomatic Gallstone Disease

Approximately 15% of the adults in the United States are estimated to have gallstones. Almost 60% to 80% of the gallstones are incidentally found during routine abdominal sonography, but most patients do not have symptoms or abdominal symptoms are not from gallbladder disease. Approximately 20% of persons with silent gallstones may develop symptoms by 20 years. It is unusual to develop gallstone-related complications without first developing at least an episode of biliary pain. Symptoms develop with a rate of 1% to 4% per year. Patients with asymptomatic gallstones do not require cholecystectomy except in countries where gallbladder carcinoma is prevalent. Box 137.1 lists indications for prophylactic cholecystectomy.

Box 137.1
Indications for Prophylactic Cholecystectomy in Patients With Silent Gallstones a

a Diabetes mellitus is not an indication for prophylactic cholecystectomy. Cholecystectomy is not performed routinely in all patients undergoing bariatric surgery.

  • 1.

    High risk for gallbladder cancer

    • Native American women with gallstones

    • Solitary stone or stone burden > 3 cm

    • Porcelain gallbladder (indication is currently questioned)

    • Gallbladder polyps > 12 mm

  • 2.

    Carriers of Salmonella typhi

  • 3.

    Sickle cell disease (calcium bilirubinate stones)

  • 4.

    Incidental cholecystectomy during another abdominal surgery (chronic hemolytic conditions, risk of malignancy, and bariatric surgery)

  • 5.

    To be considered in heart transplant patients

  • 6.

    Plan to live for long periods in remote parts of world with poor medical facilities

Porcelain gallbladder (PGB) is a rare, asymptomatic, chronic cholecystitis characterized by intramural calcification of the gallbladder wall. PGB was once considered to be a strong indicator for cholecystectomy because of its high association with gallbladder cancer. The association is currently felt to be a weak one. Patchy mucosal calcification carries a higher risk of cancer than does diffuse intramural calcification. Plain abdominal radiographs reveal an incidental calcified gallbladder. The incidence of gallbladder carcinoma is as high as 33%, and prophylactic cholecystectomy is warranted.

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