Gallbladder & extrahepatic bile ducts
Cholecystitis
Chronic cholecystitis


Topic Completed: 19 March 2020

Minor changes: 20 March 2020

Copyright: 2003-2020, PathologyOutlines.com, Inc.

PubMed Search: Chronic cholecystitis[TI] gallbladder[TI]

See Also: Diffuse lymphoplasmacytic acalculous cholecystitis

Kelsey E. McHugh, M.D.
Thomas P. Plesec, M.D.
Page views in 2019: 22,361
Page views in 2020 to date: 20,850
Cite this page: McHugh KE, Plesec TP. Chronic cholecystitis. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/gallbladderchroniccholecystitis.html. Accessed November 27th, 2020.
Definition / general
  • Chronic inflammation of the gallbladder, typically secondary to gallstones
Essential features
  • The most common disease of the gallbladder, typically secondary to cholelithiasis
  • Variety of histologic findings, including variable amounts of mononuclear cell predominant inflammation, mucosal changes including metaplasia, muscular hypertrophy and transmural fibrosis
  • Rokitansky-Aschoff sinuses and ducts of Luschka should not be mistaken for invasive adenocarcinoma
ICD coding
  • ICD-10: K81.1 - chronic cholecystitis
  • ICD-11: DC12.1 - chronic cholecystitis
Epidemiology
Pathophysiology
Etiology
Clinical features
  • Does not always cause clinical symptoms
  • Can present with dull right upper quadrant pain that radiates to mid back or right scapula (StatPearls: Chronic Cholecystitis [Accessed 19 February 2020])
  • Murphy sign: right upper abdominal pain with deep palpation
  • Abdominal discomfort often related to fatty food ingestion
  • Nausea, vomiting, bloating, flatulence
Diagnosis
Radiology description
Radiology images

Contributed by Kelsey E. McHugh, M.D.

Distended gallbladder with stones

Contracted gallbladder with stones

Thickened gallbladder wall with stones

Prognostic factors
Case reports
Treatment
Gross description
Gross images

Contributed by Kelsey E. McHugh, M.D.

Contracted gallbladder with stones

Distended gallbladder with stones

Microscopic (histologic) description
  • Variable amounts of predominantly mononuclear inflammatory infiltrate in lamina propria, which may extend into the muscularis and pericholecystic tissues
  • Inflammatory infiltrate predominantly consists of T lymphocytes, with some plasma cells, histiocytes and occasional eosinophils (Ann Diagn Pathol 2003;7:147)
  • Inflammation typically rather minimal; occasional lymphoid follicles may be seen in lamina propria
  • Hypertrophy of muscularis and variable degrees of mural fibrosis, elastosis, neural hyperplasia
  • Accentuation of Rokitansky-Aschoff sinuses (pseudodiverticula)
  • Adenomyomatous hyperplasia may occur
  • Variable mucosal changes: normal, atrophic, ulcerated, hyperplastic
  • Metaplastic changes common: foveolar metaplasia, pyloric gland metaplasia, intestinal metaplasia
  • Hyalinizing variant: dense paucicellular hyalinizing fibrosis effacing ≥ 80% of normal histologic structures, resulting in a thinned gallbladder wall with (porcelain gallbladder) or without dystrophic calcification
  • IgG4 associated variant: increased frequency of transmural lymphoplasmacytic inflammatory infiltrates, extramural inflammatory nodules, increased eosinophils, phlebitis and increased IgG4 plasma cells by immunostain
  • 2 patterns of inflammation associated with idiopathic inflammatory bowel disease: marked chronic cholecystitis (ulcerative colitis or Crohn's disease) and nodular lymphoid aggregates (Crohn's disease > ulcerative colitis) (J Crohns Colitis 2012;6:895)
  • Beware of invasive adenocarcinoma mimics: adenomyoma, Luschka ducts
  • In rare instances, reactive / hyperplastic ducts of Luschka can be seen isolated to the gallbladder adventitia (Am J Surg Pathol 2011;35:883)
Microscopic (histologic) images

Contributed by Kelsey E. McHugh, M.D.

RA sinus

RA sinuses with inspissated bile

Mucosal atrophy

Focal intestinal metaplasia


Intestinal metaplasia

Pyloric gland metaplasia

Hyalinizing cholecystitis

Virtual slides

Images hosted on other servers:

Chronic cholecystitis
with an eosinophil rich
inflammatory infiltrate

Sample pathology report
  • Gallbladder, cholecystectomy:
    • Chronic cholecystitis and cholelithiasis
Differential diagnosis
  • Normal gallbladder:
    • Lacks significant expansion of the lamina propria by an inflammatory infiltrate, thickened muscularis or mural fibrosis
  • Lymphoma:
    • Lymphoma of the gallbladder is exceedingly rare (0.1 - 0.2% of cholecystectomies) and is generally identified as part of a systemic disease
    • The most common primary lymphoma of the gallbladder is MALT lymphoma (BMJ Case Rep 2017;2017:bcr2017220161)
    • Primary MALT lymphoma of gallbladder is typically identified on presurgical imaging as gallbladder wall thickening or a polypoid lesion
  • Lymphoplasmacytic cholecystitis:
  • AIDS related cholecystitis:
    • Typically presents as acalculous cholecystitis; > 50% of cases are idiopathic (Clin Infect Dis 1995;21:852)
    • Can be related to infectious agents, particularly cytomegalovirus and cryptosporidia
    • In cryptosporidia related cases, associated inflammation may be minimal
  • Follicular cholecystitis:
    • Numerous prominent lymphoid follicles in lamina propria throughout gallbladder
    • Rare and accounts for < 0.1% of cholecystectomies (Hum Pathol 2019;88:1)
    • Up to 5% of otherwise ordinary chronic cholecystitis may show scattered, occasional follicle formation
  • Eosinophilic cholecystitis:
    • Massive infiltration of the gallbladder by sheets of eosinophils with few, if any, other intervening inflammatory cells (Am J Surg Pathol 1994;18:215)
    • Common to see eosinophils as part of the mixed inflammatory milieu of chronic (and acute) cholecystitis
  • Xanthogranulomatous cholecystitis:
    • Prominent proliferation of foamy macrophages, in addition to admixed lymphocytes, plasma cells and foreign body type giant cells
    • Thought to be secondary to mucosal ulceration or rupture of Rokitansky-Aschoff sinuses with bile extravasation
    • Grossly, may display diffuse plaque-like thickening of gallbladder wall or a discrete mass lesion (pseudotumor)
Board review style question #1
A 40 year old woman with a BMI of 36 undergoes cholecystectomy for intermittent, dull right upper quadrant abdominal pain, reproducible on physical examination with deep palpation. Sections of gallbladder wall show the following:



What is the best interpretation of these findings?

  1. Chronic cholecystitis
  2. Cystadenocarcinoma
  3. Dilated ducts of Luschka
  4. Intracholecystic papillary tubular neoplasm (ICPN)
  5. Invasive adenocarcinoma
Board review answer #1
A. Chronic cholecystitis

Comment Here

Reference: Chronic cholecystitis
Board review style question #2
What is the most common cause of elective cholecystectomy in the United States?

  1. Acute cholecystitis
  2. Chronic cholecystitis
  3. Eosinophilic cholecystitis
  4. Follicular cholecystitis
  5. Xanthogranulomatous cholecystitis
Board review answer #2
B. Chronic cholecystitis

Comment Here

Reference: Chronic cholecystitis
Board review style question #3
Which of the following variants of chronic cholecystitis has an established increased risk of associated adenocarcinoma?

  1. Adenomyomatous chronic cholecystitis
  2. Diffuse lymphoplasmacytic cholecystitis
  3. Follicular cholecystitis
  4. Hyalinizing cholecystitis
  5. IgG4 associated cholecystitis
Board review answer #3
D. Hyalinizing cholecystitis

Comment Here

Reference: Chronic cholecystitis
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