The Common Vein Copyright 2008
Alok Anand
Definition
Chronic cholecystitis is a repetitive inflammation of the gallbladder. Unlike acute cholecystitis, it is unclear whether gallstones are involved in the process and its subsequent clinical presentation of pain, although stones are present in nearly 90% of cases.
The patient may have an indolent RUQ pain, or biliary colic. It is similar to thate of acute cholecystitis, and is accompanied by nausea, vomiting and frequently intolerance of fatty foods.
There are important structural changes associated with chronic cholecystitis. Proliferation of immune cells, fibrosis, and proliferation of the mucosal epithelium. Mucosal epithelium often gives rise to the formation of deep crypts within and through the wall, often called Rokitansky-Aschoff sinuses.
Whereas acute cholecystitis often presents with fever, in chronic cholecystitis, patients are usually afebrile and do not usually have an elevated white cell count. The may have localized tenderness over the gallbladder (Murphy’s Sign). The inflammatory processes may lead to modestly abnormal liver function tests, namely high transaminase levels.
Increased dystrophic calcification may yield an accumulation of mineral called a porcelain gallbladder, which is associated with carcinoma.
In addition, obstruction and derangements of the cellular function from chronic inflammation may result in an accumulation of clear secretions, referred to as hydrops of the gallbladder.
It may result in a variety of complications similar to that of acute cholecystitis, namely bacterial superinfection, perforation with abscess formation, or rupture with bile peritonitis.
Diagnosis is often with ultrasound, and can be confirmed with CT imaginge. Findings include stones in the gallbladder. There is often a thickened gallbladder wall. In advanced cases, the wall may even be contracted.
Chronic Cholecystitis |
This is a photograph of a resected gallbladder opened longitudinally. The gallbladder is being held open by sticks, as the inflammatory process made the wall thicker and stiffer than normal. Note that on the cut face the wall is about 1 cm thick. The color is pale tan-white due to fibrosis in the wall. The multiple gallstones are expected; it would be unusual not to see them.
11930.81s gallbladder chronic cholecystitis grosspathology Courtesy Barbara Banner MD |
gallbladder dx cholelithiasis grosspathology Courtesy Barbara Banner MD |
11932.8s gallbladder chronic cholecystitis histopathology Courtesy Barbara Banner MD |
02118.8s gallbladder small stone filled contracted chronic cholecytitis CTscan Courtesy Ashley Davidoff MD copyright 2008 |
30701.8s stone cholelithiasis hyperemic wall small contracted chronic cholecytitis stomach gastrostomy redundant mucosa CTscan Courtesy Ashley Davidoff MD copyright 2008 chronic cholecytitis |
02249 liver fx mass infection abscess dx diverticulitis gallbladder gallstones dx cholelithiasis CTscan Courtesy Ashley Davidoff MD |
39408.8s gallbladder calcified stones cholelithiasis hyperemic wall cystic artery branches hyperemic mucosa and submucosa ‘kidney renal cyst pancreas chronic cholecytitis CTscan Courtesy Ashley Davidoff MD copyright 2008 |
81983c01.8s 31 F pw abdominal pain chronic cholecytitis cholelithiasis at path fluid was gelatinous green cholesterol choleliths measuring up to 6mm focal congestion of mucosa cystic duct occluded with 9mm mulberry cholesterol stone gallbladder thick wall hyperemic cholesterol crystals complex fluid in the gallbaldder fossa GBF dx acute on chronic cholecystitis USscan ultrasound color flow doppler Courtesy Ashley Davidoff MD copyright 2008 |
45092 45092b02 gallbladder fx cholelithiasiscompletely occupying gallbladder lumen CTscan Courtesy Ashley Davidoff MD |
25306.8s small cholesterol crystals stones floaters hyperemic wall chronic cholecytitis gas air cholelithiasis CTscan Courtesy Ashley Davidoff MD copyright 2008 |
78352.8s obese female gallbladder layering hyperdense stones cholelithiasis hyperemic wall hyperemic mucosa and submucosa chronic cholecystitis CTscan Courtesy Ashley Davidoff MD copyright 2008 |
16239c.8s gallbladder stone cholelithiasis wall thickened thick wall enhancing wall dx chronic cholecystitis bile duct cholangiocarcinoma MRI with and without contrast |
04731.8s gallbladder fibrosis across the fundus filling defect chronic cholecystitis OCG historical stricture Courtesy Ashley Davidoff MD copyright 2008 |
11530.81s gallbladder fibrosis across the fundus filling defect chronic cholecystitis cholelithiasis stone in fundus OCG historical stricture Courtesy Ashley Davidoff MD copyright 2008 |
31285.8s 64 male gallbladder fibrosis across the fundus filling defect chronic cholecystitis cholelithiasis stone in fundus Ctscan figure of eight stricture Courtesy Ashley Davidoff MD copyright 2008 |
30701.8s stone cholelithiasis hyperemic wall small contracted chronic cholecytitis stomach gastrostomy redundant mucosa CTscan Courtesy Ashley Davidoff MD copyright 2008 chronic cholecytitis |
81916.8s gallbladder stone cholelithiasis thick wall thickened wall small contracted chronic cholecystitis CTscan Courtesy Ashley Davidoff MD copyright 2008 |
This photomicrograph at low power shows most of the full thickness of the wall of a gallbladder. The lumen is the clear area at one side of the picture. The pale homogeneous area down the middle is fibrous replacement of the wall. The little nubbin of tissue and cholesterol clefts along the lumen represents what is left of the mucosa. The darker, zig-zag structure at the side opposite the lumen represents where the gallbladder wall is calcified. This calcification and fibrosis of the entire gallbladder wall is the diagnostic feature of porcelain gallbladder.
11940.8s gallbladder porcelain gallbladder histopathology Courtesy Barbara Banner MD |