Chronic cholecystitis

With acute cholecystitis, a gallstone gets lodged in the cystic duct, or maybe in the common bile duct, and then causes acute inflammation, pain, and possibly, but not usually, infection; almost all cases of acute cholecystitis though, about 90%, clear up after about a month and the gallstone dislodges.

It’s possible though, that gallstones get stuck again, and then dislodge, and then get stuck again, and dislodge, and so on.

So over time, you can imagine the gall bladder walls taking a serious beating, and as those epithelial cells go through this cycle of inflammation over and over again, patients are essentially in this constant state of inflammation, also known as chronic cholecystitis.

After a while, they can begin to show signs of cellular damage and the epithelial cells can possibly even die off. Some patients might not even have had cases of acute cholecystitis where the gallstone gets lodged in the ducts, and sometimes they just have gallstones that cause this constant state of irritation and mild inflammation just by being in the gallbladder.

Gallstones can be made up of bilirubin, called pigment gallstones, or cholesterol, called cholesterol stones, or maybe they’re made up of both, and when they roll around and are in contact with the epithelial cells, they can cause inflammation.

One study found that cholesterol stones in particular might have a more potent ability to stimulate inflammation of the gallbladder epithelial cells.

Whatever the case, chronic inflammation can take its toll, and changes in the gallbladder wall structure can start to take place.

Normally, the gallbladder mucosa is nice and flat and uniform, but when they’re under this constant state of inflammation and irritation, they start to change shape with deep grooves or pockets of mucosa, like this one here, this is called a rokatansky-aschoff sinus, see how it dives down and forms this little cave-like structure, that’s definitely not the normal structure of a gallbladder mucosa.

This chronic inflammation leaves the gallbladder in a pretty sensitive state, and patients with chronic cholecystitis often feel pain after eating a meal, because the inflamed gallbladder starts contracting in an effort to squeeze out some bile to the small intestine and help with digesting that meal.

That pain can usually be felt in the right upper quadrant and can radiate up to the right scapula and shoulder area. As more and more damage is done to the epithelial cells and the gallbladder continues to be in this chronic state of inflammation with potential cell death, the epithelial tissue undergoes fibrosis and calcification, and leads to a condition called porcelain gallbladder, because it takes on a more bluish discoloration and becomes hard and brittle.

Since it starts to calcify, it can also usually be seen on x-ray, like this one here. Why it starts to calcify though still remains a bit of a debate, though, some think it’s part of the natural progression of fibrosis and scarring from longstanding inflammation, but others suggest that it might be due to the stagnation of bile, which might cause calcium carbonate bile salts to precipitate out and deposit into the walls.

Either way, this thing’s gotta go, because all that inflammation and cell damage over time raises the risk of developing gallbladder cancer, so patients with porcelain gallbladder typically get it removed, called a cholecystectomy.

Depending on the severity of the chronic cholecystitis, removal of the gallbladder might be needed even if it hasn’t progressed to the porcelain state.