Cholelithiasis and Cholecystitis

Cholelithiasis is the presence of stones (calculi) in the gallbladder, and cholecystitis is inflammation of the gallbladder, most often caused when a stone obstructs the cystic duct. Together they form the commonest indication for biliary surgery, with laparoscopic cholecystectomy the usual definitive treatment for symptomatic disease.

Definition

Cholelithiasis denotes gallstones within the gallbladder; cholecystitis denotes inflammation of the gallbladder, typically acute calculous cholecystitis arising from cystic-duct obstruction by a stone.

Scope

This topic covers gallstone formation and its common forms, the distinction between asymptomatic gallstones, biliary colic, and acute cholecystitis, the standardised diagnosis and severity grading of acute cholecystitis, and the role of cholecystectomy. It is a reference description of the conditions and is not individualized clinical advice.

Key concepts

• Cholesterol versus pigment gallstones
• Biliary colic versus acute cholecystitis
• Cystic-duct obstruction
• Murphy sign and ultrasound diagnosis
• Tokyo Guidelines severity grading (Grade I-III)
• Laparoscopic cholecystectomy
• Acalculous cholecystitis

Mechanisms

Most gallstones are cholesterol stones that form when bile becomes supersaturated with cholesterol, with crystal nucleation and impaired gallbladder emptying promoting stone growth; pigment stones arise from excess unconjugated bilirubin. Acute calculous cholecystitis develops when a stone impacts in the cystic duct or gallbladder neck, causing obstruction, distension, mucosal injury, and inflammation that may progress to infection, gangrene, or perforation if unrelieved. Acalculous cholecystitis can occur without stones, typically in critically ill patients, through gallbladder stasis and ischaemia.

Clinical relevance

Gallstone disease ranges from incidentally found, asymptomatic stones to biliary colic and acute cholecystitis; the Tokyo Guidelines provide standardised diagnostic criteria and a three-tier severity grading that inform decisions about timing of cholecystectomy and use of drainage. This entry summarises how the conditions are described and graded for reference and educational purposes and does not provide individualized treatment recommendations.

Epidemiology

Gallstones are common, affecting a substantial proportion of adults in Western populations, with higher prevalence in women, with increasing age, and in association with obesity; the majority of people with gallstones remain asymptomatic, and only a minority develop biliary colic or cholecystitis.

Evidence & guidelines

The Tokyo Guidelines 2018 define diagnostic criteria and severity grades for acute cholecystitis and set out a management flowchart and antimicrobial recommendations, providing the principal international reference framework for the condition.

Debates

Timing of cholecystectomy in acute cholecystitis

The Tokyo Guidelines management flowchart addresses when early cholecystectomy is appropriate versus initial conservative management or gallbladder drainage according to severity grade and patient fitness, a judgement that remains individualized.

Seminal works

• yokoe-2018
• okamoto-2018
• shaffer-2006

Frequently asked questions

What is the difference between cholelithiasis and cholecystitis?

Cholelithiasis means stones are present in the gallbladder, whereas cholecystitis means the gallbladder is inflamed - most often because a stone has obstructed the cystic duct.

Do all gallstones need surgery?

No. Most gallstones are asymptomatic and are generally not operated on; surgery is typically considered for symptomatic disease such as biliary colic or acute cholecystitis, but the decision is individualized and outside the scope of this reference entry.