Cholecystitis: acute, acalculous and chronic
- Lesion
Cholecystitis is an inflamed gallbladder, usually because a stone blocks its outlet; it can be sudden or long-lasting.
What it is
Acute calculous cholecystitis follows obstruction of the gallbladder neck or cystic duct by a stone: chemical injury from bile, then often bacterial infection. Acute acalculous cholecystitis occurs without stones in critically ill patients, mainly from ischemia and stasis. Chronic cholecystitis, nearly always with stones, results from repeated mild inflammation and is the most common indication for cholecystectomy. Complications include gangrene, perforation, empyema and fistula.
Structure
- Acute: enlarged, tense, red or green-black gallbladder with fibrinous serosal exudate; edema, hemorrhage, neutrophils, ulceration.
- Chronic: shrunken or normal-size gallbladder with a thickened grey-white wall; lymphocytes, fibrosis, Rokitansky-Aschoff sinuses.
- Cholesterolosis: lipid-laden macrophages in the lamina propria (strawberry gallbladder), a separate incidental finding.
Step by step
- A stone impacts in the gallbladder neck or cystic duct.
- Trapped bile becomes concentrated; phospholipases release toxic lysolecithin.
- Mucosal protection fails, prostaglandins cause inflammation and wall edema.
- Distension and pressure reduce blood flow; bacteria (E. coli, enterococci, anaerobes) invade.
- The wall may become gangrenous and perforate, or the lumen fills with pus (empyema).
Types of cholecystitis
| Type | Setting | Pathology | Risk |
|---|---|---|---|
| Acute calculous | Stone obstructs the outlet | Edema, hemorrhage, neutrophils | Empyema, gangrene, perforation |
| Acute acalculous | Critical illness, ischemia, stasis | Ischemic necrosis, inflammation | Gangrene and perforation more often |
| Chronic | Repeated attacks, almost always stones | Fibrosis, mononuclear cells, Rokitansky-Aschoff sinuses | Porcelain gallbladder, carcinoma |
| Xanthogranulomatous | Chronic obstruction with rupture of sinuses | Foamy macrophages, fibrosis, mass | Mimics carcinoma |
Test yourself
Think of the answer, then tap the question to see it.
What starts the inflammation in acute calculous cholecystitis?
Obstruction of the outlet by a stone, with chemical injury from lysolecithin and loss of the mucus barrier; infection usually comes later.
In which patients does acalculous cholecystitis typically occur?
Critically ill patients: after sepsis, major surgery, trauma, burns or prolonged parenteral nutrition.
What are Rokitansky-Aschoff sinuses?
Outpouchings of gallbladder mucosa into the thickened wall, typical of chronic cholecystitis.
What is a porcelain gallbladder?
A gallbladder with calcified wall from chronic inflammation, associated with carcinoma.
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Educational content on the mechanisms of disease; not a diagnostic or treatment guide and no substitute for a health professional's advice. No doses are given.
Sources: Acute Cholecystitis (StatPearls (NCBI Bookshelf), 2025).
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Representative model, for educational purposes only.