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# 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.

Updated Nov 12, 2026

## Key points

- Acute calculous: stone in the neck or cystic duct; phospholipase converts lecithin to lysolecithin, which injures mucosa; infection follows.
- Acalculous: sepsis, burns, trauma, major surgery, prolonged fasting or parenteral nutrition, vasculitis; higher risk of gangrene.
- Chronic: thick fibrotic wall, mononuclear infiltrate, Rokitansky-Aschoff sinuses (outpouchings of mucosa into the wall).
- Porcelain gallbladder: dystrophic calcification of the wall in chronic inflammation, linked to carcinoma.
- Xanthogranulomatous cholecystitis: foamy macrophages and fibrosis forming a mass that can mimic cancer.
- Murphy sign and right upper quadrant pain with fever and leukocytosis suggest acute cholecystitis.

## 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](https://durgical.com/en/conditions/acute-cholecystitis/) | 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 |

## Memory aid

Block, burn, bugs: a stone blocks, lysolecithin burns, bacteria finish the job.

## 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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## Elsewhere in DurgiPedia

- [Gallbladder and bile ducts](https://durgical.com/en/histology/gallbladder-and-bile-ducts/)

## Connections

## Related 5

- [Gallstones: cholesterol vs pigment](https://durgical.com/en/general-pathology/gallstones-cholesterol-vs-pigment/)
- [Gallbladder carcinoma](https://durgical.com/en/general-pathology/gallbladder-carcinoma/)
- [Patterns of acute inflammation: serous, fibrinous, purulent, abscess, ulcer](https://durgical.com/en/general-pathology/patterns-of-acute-inflammation-serous-fibrinous-purulent-abscess-ulcer/)
- [Chronic inflammation: causes, cells and features](https://durgical.com/en/general-pathology/chronic-inflammation-causes-cells-and-features/)
- [Pathologic calcification: dystrophic vs metastatic](https://durgical.com/en/general-pathology/pathologic-calcification-dystrophic-vs-metastatic/)

## Related conditions 5

- [Acute cholecystitis](https://durgical.com/en/conditions/acute-cholecystitis/)
- [Gallstones (cholelithiasis)](https://durgical.com/en/conditions/gallstones/)
- [Acute cholangitis](https://durgical.com/en/conditions/acute-cholangitis/)
- [Sepsis and septic shock](https://durgical.com/en/conditions/sepsis-and-septic-shock/)
- [Peritonitis](https://durgical.com/en/conditions/peritonitis/)

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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](https://www.ncbi.nlm.nih.gov/books/NBK459171/) (StatPearls (NCBI Bookshelf), 2025).

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Source: https://durgical.com/en/general-pathology/cholecystitis-acute-acalculous-and-chronic/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/general-pathology/cholecystitis-acute-acalculous-and-chronic/