Cholecystitis, Cholelithiasis, and Choledocholithiasis

Chronic cholecystitis– Acute or chronic inflammation of the gallbladder (cholecystitis) usually associated with gallstones (chole-lithiasis), which lodge in the cystic duct. Choledocholithiasis is obstruction of the common bile duct by gallstones.

Causes and Incidence

The cause of cholelithiasis is not clear, although abnormal metabolism of cholesterol and bile salts plays a crucial role. Other predisposing factors are a high-calorie, high-cholesterol diet; obesity; elevated estrogen levels; use of cholesterol-lowering drugs, and a familial history of the disorder. Most cases of acute cholecystitis (95%) are caused by gallstones lodged in the cystic duct; 5% of cases are associated with trauma, burns, infection, prolonged anesthesia, or critical illness. Chronic cholecystitis is caused by repeated acute episodes. Choledocholithiasis results when gallstones lodge in the common bile duct.

An estimated 35 million people in the United States have cholelithiasis, and 1 million new cases are diagnosed each year. Gallstones occur more often in women and in certain ethnic groups, such as Native Americans. The incidence increases with age.

Disease Process

Gallstone formation begins with supersaturation of bile with an insoluble solute such as cholesterol or calcium bilirubinate. Rapid precipitation of cholesterol crystals occurs through some as yet unexplained process involving mucin glycoproteins. The precipitates grow under static conditions (i.e., reduced gallbladder motility or contractility) and form macroscopic stones. When the stone obstructs a cystic duct, the gallbladder distends and the wall becomes edematous and compresses capillaries and lymphatic channels, producing inflammation of the mucosa. The inflamed, ischemic mucosa allows reabsorption of bile salts, which sets up further damage. If the condition goes unchecked, the wall becomes friable and necrotic and is susceptible to perforation. When a stone obstructs the common bile duct, it often causes extrahepatic obstructive jaundice, infection, pancreatitis, or liver disease.



Acute cholecystitis
Colicky pain in right upper quadrant and right lower scapula; nausea, vomiting; low-grade fever.

Chronic cholecystitis
Anorexia, flatulence, nausea, fat intolerance; episodic or diffuse abdominal pain, heartburn.

Asymptomatic, or jaundice and pain.

Potential Complications

Necrosis and perforation of the gallbladder, with generalized peritonitis; cholangitis with or without septic shock; pancreatitis; biliary cirrhosis; and bowel obstruction with perforation and peritonitis are all complications of biliary disease.

Diagnostic Tests

To visualize gallstones.

Biliary scintigraphy
If common bile duct is obstructed, gallbladder cannot be visualized on scan.

Transhepatic cholangiography
To visualize stones in common bile duct.


Laparoscopic cholecystectomy to remove gallbladder; endoscopic procedure to remove stones by balloon or basket; sphincterotomy to release ductal stones into intestine; laparotomy with cholecystectomy and T-tube placement in some cases when other methods are not appropriate.

Oral urodisol to dissolve stone; methylterbutyl ether instilled directly into gallbladder via percutaneous transhepatic catheter to dissolve stone; antiinfective drugs; analgesics.

Lithotripsy delivers external shock waves to pulverize stones.