Chronic cholecystitis pathophysiology

Inflammation of the gallbladder is termed as cholecystitis. Chronic calculous cholecystitis is usually caused by the mechanical obstruction due to gallstones. Chronic acalculous cholecystitis is caused predominantly by the gallbladder stasis. Lith gene is also involved in the pathogenesis of cholecystitis. Cholecystitis is more common in siblings and first degree relatives of affected persons. On gross pathology, chronic cholecystitis usually shows enlarged or distended gallbladder and serosal or mucosal exudates. Fibrosis of gallbladder may also be seen. Microscopic pathology shows lymphocytic inflammatory infiltrates, metaplasia, and lipid or mucolipid accumulations in the gallbladder wall.

Inflammation of the gallbladder is termed as cholecystitis. Chronic calculous cholecystitis is usually caused by the mechanical obstruction due to gallstones. Chronic acalculous cholecystitis is caused predominantly by the gallbladder stasis. The pathogenesis of chronic cholecystitis involves the following:^{[1][2][3][4][5][6]}

The following are a few important features about the gallbladder obstruction leading to chronic cholecystitis:

• Gallstones are one of the major causes of cholecystitis. These cause physical obstruction to the lumen of the neck or cystic duct. This results in an increase in the intraluminal pressure. The degree and duration of obstruction are the two main factors that determine its progression.
• Partial obstruction of short duration may cause biliary colic. Long-term obstruction may progress to chronic cholecystitis.
• Some studies suggest that the pancreatic biliary reflux plays a role in the development of chronic cholecystitis.

Bile stasis results in acute acalculous cholecystitis but can also lead to chronic acalculous cholecystitis.

• Loss of fluids, opioid drugs, positive pressure ventilation, and other factors cause an increased concentration of bile in the biliary tract.
• Bile contains phosphatidyl choline, which in increased concentrations can cause mucosal disruption.

Following are a few important genetic aspects related to chronic cholecystitis:

• Cholecystitis is more common in siblings and first degree relatives of affected persons.^[7][8]
• Lith gene is involved in the pathogenesis of cholecystitis.^[9]
• Mutations in the hepatic cholesterol transporter ABCG8 also predispose an individual to the develop gallstones.^[10]

The following conditions are associated with gallstones:^[11]

• Diabetes
• Insulin resistance
• Cardiovascular diseases
• Non-alcoholic fatty liver disease (NAFLD)
• Gastrointestinal malignancies:
  • Gastric cancer
  • Hepatocellular carcinoma
  • Cholangiocarcinoma
  • Pancreatic cancer
  • Cancer of the ampulla of Vater

On gross pathology, chronic cholecystitis may have the following features:^[12][13][14]

• Enlarged or distended of gallbladder
• Serosal or mucosal exudates
• Thickened wall with hemorrhage and edema

On microscopic pathology, chronic cholecystitis has the following features:^[14][6]

• Lymphocytic infiltrates and metaplasia
• Fibrosis (due to collagen deposition)
• Lipid and mucolipid acuumulation in gallbladder wall
• Granulation tissue

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