Chronic cholecystitis is chronic inflammation of the gallbladder due to recurrent gallstone irritation. Prolonged mucosal damage leads to fibrosis, wall thickening, and loss of gallbladder function. There is usually a history of recurrent biliary colic attacks. US shows contraction failure (functional impairment), wall thickening, and gallstones. In advanced cases, the gallbladder may be shrunken (contracture) and fibrotic. Porcelain gallbladder (mural calcification) is a consequence of chronic cholecystitis and carries malignancy risk.
Age Range
35-80
Peak Age
55
Gender
Female predominant
Prevalence
Common
The pathophysiology of chronic cholecystitis is based on cycles of recurrent gallstone obstruction and mechanical irritation. Each acute attack damages the gallbladder mucosa, and fibrosis develops during the healing process. Repeated damage-repair cycles lead to wall thickening, fibrotic replacement of muscularis propria, and mucosal atrophy. The fibrotic wall prevents normal contraction — decreased contraction after fatty meal on US reflects this functional impairment. In advanced stages, the gallbladder may be entirely fibrotic and shrunken (contracture). Chronic inflammation creates a substrate for dysplasia and metaplasia development — therefore porcelain gallbladder and long-standing chronic cholecystitis increase malignancy risk. Histologically, mucosal atrophy, Rokitansky-Aschoff sinus proliferation, transmural fibrosis, and chronic inflammatory infiltrate are characteristic.
A triad consisting of thickened wall (hypoechoic line), strong echo reflected from stone in the lumen (hyperechoic line), and acoustic shadow in the contracted gallbladder. This complex forms a compact structure in the gallbladder fossa and represents advanced chronic cholecystitis. In the presence of WES complex, the gallbladder lumen is nearly completely obliterated.
Diffuse smooth wall thickening (>3 mm) with gallstones (hyperechoic + acoustic shadow). The wall has a homogeneous hypoechoic or isoechoic appearance — unlike the layered (edematous) appearance in acute cholecystitis, smooth fibrotic thickening is seen.
Report Sentence
Diffuse smooth wall thickening (… mm) with gallstones is seen in the gallbladder, consistent with chronic cholecystitis.
Shrunken, contracted gallbladder — the lumen may be very narrow or obliterated. Indicates advanced fibrosis and loss of function. Wall-echo-shadow (WES) complex: in contracted gallbladder, wall + echo + shadow are seen together.
Report Sentence
The gallbladder is shrunken and contracted with WES complex — consistent with chronic cholecystitis.
Diffuse wall thickening with homogeneous enhancement on CT. Pericholecystic fat stranding is usually absent (unlike acute cholecystitis). Wall calcifications may be seen (progression toward porcelain gallbladder).
Report Sentence
Diffuse wall thickening and enhancement are observed in the gallbladder on CT, consistent with chronic cholecystitis.
Low signal in the gallbladder wall on T2-weighted MRI — reflecting the low water content of fibrotic tissue. Different from the T2 hyperintense edematous wall in acute cholecystitis. T2 hypointense gallstones and/or debris may be seen in the lumen.
Report Sentence
Low signal consistent with fibrosis is seen in the gallbladder wall on T2-weighted MRI.
Reduced wall vascularity on Doppler US — unlike the hypervascularity in acute cholecystitis. Reflects fibrotic replacement of vascular structures in the wall.
Report Sentence
No significant increase in wall vascularity is observed on Doppler US.
Delayed gallbladder filling or low ejection fraction (below 35%) on HIDA scintigraphy. No complete obstruction but demonstrates functional impairment. The most reliable functional test for chronic cholecystitis.
Report Sentence
The gallbladder shows delayed filling on HIDA scintigraphy with low ejection fraction after CCK (…%).
Criteria
Characterized by transmural fibrosis as a result of recurrent inflammation. Gallbladder is shrunken, wall is thick and rigid.
Distinct Features
WES complex on US, contracted gallbladder. Small thick-walled gallbladder on CT. T2 hypointense wall (fibrosis) on MRI.
Criteria
Excessive distension of the gallbladder with mucin and clear fluid due to chronic cystic duct obstruction. No active inflammation.
Distinct Features
Marked distension (>10 cm), thin wall, clear luminal content on US. No acute inflammatory findings. Stone may be impacted at the neck.
Criteria
Beginning of wall calcification as an advanced stage of chronic cholecystitis. Partial mural calcifications are observed.
Distinct Features
Focal or partial wall calcifications on CT. Malignancy risk is lower than complete porcelain gallbladder but follow-up is needed.
Distinguishing Feature
Acute cholecystitis has pericholecystic fluid, positive sonographic Murphy sign, layered appearance of wall edema, and acute clinical presentation (fever, leukocytosis). These are absent in chronic cholecystitis.
Distinguishing Feature
Gallbladder carcinoma shows focal/asymmetric wall thickening or intraluminal mass, liver invasion, and lymphadenopathy. In chronic cholecystitis, wall thickening is diffuse and symmetric.
Distinguishing Feature
In adenomyomatosis, comet-tail artifact and intramural cystic spaces (Rokitansky-Aschoff sinuses) are pathognomonic. In chronic cholecystitis, homogeneous fibrotic thickening is seen.
Distinguishing Feature
In porcelain gallbladder, complete or near-complete mural calcification is pathognomonic. In chronic cholecystitis, calcification is absent or minimal. CT confirms the porcelain diagnosis.
Urgency
routineManagement
surgicalBiopsy
Not NeededFollow-up
specialist-referralChronic cholecystitis is an elective surgical indication. Laparoscopic cholecystectomy is standard treatment in symptomatic patients. In asymptomatic chronic cholecystitis, surgical decision is based on the patient's risk of becoming symptomatic and comorbidities. Development of porcelain gallbladder is an indication for prophylactic cholecystectomy due to malignancy risk. Biopsy is not needed — pathological examination is performed on the surgical specimen. Contrast-enhanced CT or MRCP is recommended preoperatively to exclude liver invasion and choledocholithiasis.
Chronic cholecystitis is an indication for elective laparoscopic cholecystectomy. Wall calcification (porcelain gallbladder) increases the risk of gallbladder carcinoma and prophylactic cholecystectomy is recommended.