Gallbladder & extrahepatic bile ducts
Cholecystitis
Gangrenous cholecystitis
Authors: Uzayr Arif, D.O., Annika L. Windon, M.D.
Editorial Board Member: Danielle Hutchings, M.D.
Deputy Editor-in-Chief: Aaron R. Huber, D.O.
Last author update: 15 April 2025
Last staff update: 15 April 2025
Copyright: 2003-2025, PathologyOutlines.com, Inc.
PubMed Search: Gangrenous cholecystitis
Table of Contents
Definition / general | Essential features | Terminology | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Laboratory | Radiology description | Radiology images | Prognostic factors | Case reports | Treatment | Clinical images | Gross description | Gross images | Microscopic (histologic) description | Microscopic (histologic) images | Sample pathology report | Differential diagnosis | Practice question #1 | Practice answer #1 | Practice question #2 | Practice answer #2Cite this page: Arif U, Windon AL. Gangrenous cholecystitis. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/gallbladdergangrenouschol.html. Accessed April 29th, 2025.
Definition / general
- Severe form of acute cholecystitis characterized by transmural acute inflammation and coagulative necrosis, with complications that include perforation and pericholecystic adhesions or abscess formation
Essential features
- Histologically distinguished from acute cholecystitis by the presence of transmural necrosis and absence of mucosa and muscularis
- Higher morbidity, mortality and complication rates compared to acute cholecystitis
- May develop secondary infection with gas producing bacteria (emphysematous)
- Surgically challenging; higher rate of open cholecystectomy or conversion from laparoscopic to open approach
Terminology
- Acute gangrenous cholecystitis
- Acute necrotizing cholecystitis
ICD coding
- ICD-10: K82.A1 - gangrene of gallbladder in cholecystitis
Epidemiology
- Constitutes 2 - 40% of all acute cholecystitis cases (J Surg Res 2015;197:18)
- Risk factors include age (40 - 60 years), male sex, cardiovascular disease, trauma, history of alcohol abuse, preoperative dyspnea, diabetes and surrogates of poor health, including nonindependent functional status, elevated white blood cell count and abnormal hematocrit (J Surg Res 2015;197:18, Int Surg 2015;100:254, Aust N Z J Surg 2000;70:428)
Sites
- Gallbladder
Pathophysiology
- Follows an episode of acute cholecystitis with occlusion of the cystic duct and typically with calculi, leading to increased luminal pressure, dilation of the gallbladder wall, mural edema and vascular insufficiency (Am J Surg 2003;186:481)
- Mucosal damage and trauma by gallstones, concentrated bile or cholesterol and release of inflammatory mediators, including prostaglandins and phospholipases from epithelial injury, leading to mucosal necrosis and inflammation (Am J Surg 2003;186:481)
- Severe transmural acute inflammation and ischemia lead to coagulative necrosis (Int Surg 2015;100:254)
- Eventual wall perforation with peritonitis
- Secondary infection by gas producing bacteria may lead to emphysematous changes
- Causative organisms include Escherichia coli, Aerobacter aerogens, Klebsiella spp. and Salmonella spp.
Etiology
- Presence of calculi results in blockage of cystic duct
- Progression from acute cholecystitis in patients with other comorbid conditions
- Delay in hospital admission (and surgery) is considered a major factor in progression from acute to gangrenous cholecystitis and may necessitate open cholecystectomy (J Clin Gastroenterol 2004;38:710, Am J Surg 1999;178:303)
Clinical features
- Similar clinical presentation to acute cholecystitis, including right upper quadrant pain accompanied by abdominal guarding and local tenderness (Murphy sign), nausea, vomiting, anorexia and abdominal distention (Int Surg 2015;100:254)
- Associated with comorbidities such as diabetes, cardiovascular disease and trauma (Surgery 1999;126:680)
Diagnosis
- Abdominal ultrasound, computed tomography (CT) scan, clinical history and presentation
- Confirmation of gangrenous changes on histopathological examination of cholecystectomy specimen
Laboratory
- Leukocytosis, transaminitis, hyperbilirubinemia and elevated alkaline phosphatase in advanced cases where gallbladder distention impinges bile ducts (Int Surg 2015;100:254)
- Leukopenia may develop in the setting of sepsis (Int Surg 2015;100:254)
- Elevated C reactive protein (CRP) may indicate advanced acute cholecystitis / gangrenous cholecystitis (J Gastrointest Surg 2020;24:2766)
Radiology description
- CT and magnetic resonance imaging (MRI)
- Gallbladder distension, air in the wall or lumen, irregular or absent gallbladder wall enhancement, intraluminal membranes, mural striations, pericholecystic fluid or abscess formation (AJR Am J Roentgenol 2002;178:275, Indian J Radiol Imaging 2018;28:49)
- Ultrasonography (US)
- Gallbladder wall thickening (> 5 mm) and edema (Ann Hepatobiliary Pancreat Surg 2019;23:228)
- Pericholecystic fluid (Int Surg 2015;100:254)
Radiology images
Images hosted on other servers:
Gallbladder wall irregularity (MRI)
Mural striations / sloughed membranes (US)
Gallbladder necrosis (CT)
Prognostic factors
- Increased rates of mortality, complications and hospital length of stay compared to acute cholecystitis (J Surg Res 2015;197:18)
- Independently predictive factors (for gangrenous cholecystitis in acute cholecystitis patients)
- Diabetes mellitus, leukocytosis (white blood cells [WBCs] ≥ 15,000 mm3), alanine transaminase (ALT) ≥ 50 U/L, aspartate aminotransferase (AST) ≥ 43 U/L, alkaline phosphatase ≥ 200 U/L, age > 51 years and ultrasonographic evidence of pericholecystic fluid (Am J Surg 2004;188:463)
Case reports
- 59 year old man with COVID-19 and gangrenous cholecystitis (World J Emerg Surg 2020;15:43)
- 77 year old man with perforated gangrenous cholecystitis, cholecystoduodenal fistula and intestinal obstruction (Asian J Surg 2024;47:4958)
- 80 year old woman with gangrenous gallbladder presenting as gastroesophageal reflux disease (Int J Surg Case Rep 2020;76:315)
- 83 year old man with severe diabetic neuropathy and gangrenous cholecystitis (World J Clin Cases 2018;6:1007)
- Woman in her 90s with gallbladder torsion and gangrenous cholecystitis (J Surg Case Rep 2023;2023:rjad252)
Treatment
- Emergent cholecystectomy
- Often surgically challenging with open or conversion to open cholecystectomy (J Surg Res 2015;197:18)
- If recognized preoperatively, percutaneous cholecystostomy tube placement for source control and interval reduction in perihilar inflammation (J Surg Res 2015;197:18)
Clinical images
Images hosted on other servers:
Gangrenous and necrotic gallbladder
Gross description
- Edematous, enlarged gallbladder with thickened wall, vascular congestion and hemorrhage (Surgery 1999;126:680, Aust N Z J Surg 2000;70:428)
- Mucosal surface may display dusky red-brown to green-black discoloration with depressed areas of necrosis
- Perforation with serosal adhesions, fibrinopurulent exudates and granulation tissue may be evident (Int Surg 2015;100:254)
- Gallstones may be present in the lumen, neck or cystic duct and occasionally appear admixed with thick, cloudy bile
Gross images
Contributed by Danielle Hutchings, M.D.
Enlarged gallbladder with necrosis
Fragmented gallbladder with hemorrhage and necrosis
Perforation
Images hosted on other servers:
Gallbladder with hemorrhagic wall
Microscopic (histologic) description
- Transmural acute inflammation with coagulative necrosis, edematous and hemorrhagic changes within the wall (Int Surg 2015;100:254)
- Erosion or sloughing of the mucosa with absence of the muscularis and replacement by necrotic debris, neutrophils and granulation tissue
- Areas of perforation may have associated acute serositis, necroinflammatory exudate and pericholecystic serosal adhesions with extramural abscess formation (Int Surg 2015;100:254)
Microscopic (histologic) images
Contributed by Uzayr Arif, D.O. and Annika L. Windon, M.D.
Mucosal necrosis
Mucosal necrosis and inflammation
Transmural inflammation
Transmural necrosis, inflammation, hemorrhage
Transmural necrosis and inflammation
Serositis
Sample pathology report
- Gallbladder, cholecystectomy:
- Acute gangrenous cholecystitis with cholelithiasis
Differential diagnosis
- Acute cholecystitis:
- Similar features but less robust inflammation and no mucosal or transmural coagulative necrosis
- Gallbladder wall edema and mucosal erosions may be present
- Emphysematous cholecystitis:
- Acute cholecystitis injury pattern with gas in the gallbladder wall
- Associated with Escherichia coli, Aerobacter aerogens, Klebsiella spp. and Salmonella infections
Practice question #1
A 53 year old man presents with right upper quadrant abdominal pain, guarding and local tenderness. An ultrasound of the gallbladder demonstrates wall thickening, mural striations and gallstones. The patient undergoes an open cholecystectomy and a representative section of the gallbladder fundus is taken for histologic examination (shown above). What is the diagnosis?
- Acute acalculous cholecystitis
- Acute cholecystitis
- Acute gangrenous cholecystitis with cholelithiasis
- Gallbladder adenocarcinoma
Practice answer #1
C. Acute gangrenous cholecystitis with cholelithiasis. The image shows a section of an acutely inflamed, thickened gallbladder wall with hemorrhage, transmural inflammation and necrosis. Gallstones were visualized on imaging. Answers A and B are incorrect because while this could represent a severe form of acute cholecystitis, the degree of inflammation and presence of transmural necrosis better supports gangrenous cholecystitis. Answer D is incorrect because gallbladder adenocarcinoma would be characterized by infiltrative glands, which are not present in the depicted section.
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Practice question #2
Which condition is commonly associated with gangrenous cholecystitis?
- Diabetes
- Hypercholesterolemia
- Malignancy
- Menopause
Practice answer #2
A. Diabetes. Gangrenous cholecystitis typically follows an episode of acute cholecystitis. Common associations include diabetes, cardiovascular disease and trauma. Other risk factors include age (40 - 60 years), male sex and a history of alcohol abuse. Answers B, C and D are incorrect because hypercholesterolemia, menopause and gallbladder malignancy have not been shown to be associated with this condition.
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