Symptoms of Chronic Cholecystitis
Chronic cholecystitis typically presents with recurrent episodes of right upper quadrant or epigastric pain lasting more than one hour, occurring predominantly at night, and is associated with gallstones in 95% of cases. 1
Primary Pain Characteristics
The hallmark symptom is biliary colic with specific features that distinguish it from other abdominal conditions:
- Location: Right upper quadrant pain extending to the epigastrium occurs in 72-93% of patients, with pain distributed across both regions in approximately 66% of cases 1, 2
- Radiation: Pain radiates to the upper back or right infrascapular area in 63% of patients 3, 2
- Duration: Episodes typically last from 30 minutes to several hours, with 85% lasting more than one hour and rarely less than 30 minutes 3, 4, 2
- Timing: Pain attacks occur predominantly in the late evening or at night in 77% of patients 2
- Pattern: A characteristic pattern of incipient warning pain building to a steady state before subsiding is present in 90% of patients 2
- Intensity: Mean pain severity scores are very high (90 mm on a 0-100 visual analogue scale) 2
Associated Symptoms
Beyond pain, patients commonly experience:
- Behavioral response: An urge to walk around during attacks occurs in 71% of patients 2
- Nausea and vomiting: Present in 38-48% of elderly patients 1
- Anorexia: Loss of appetite is common during symptomatic episodes 3
- Food intolerance: 66% of patients report intolerance to at least one type of food, though only 48% specifically to fatty foods 2
- Functional dyspepsia: The vast majority experience associated gastroesophageal reflux, dyspepsia, or irritable bowel symptoms during attacks 2
Physical Examination Findings
Clinical signs are less reliable than symptoms but may include:
- Murphy's sign: Present in only 43-48% of cases with sensitivity of 0.48 and specificity of 0.79 in elderly patients 5, 3
- Abdominal tenderness: Reported in 64.7% of patients over 65 years old 1
- Fever: May be present but is not a defining feature of chronic cholecystitis; when present in 36-74% of cases, temperature >38°C occurs in only 6.4-10% 1, 5
Important Clinical Distinctions
Chronic cholecystitis differs from acute cholecystitis in several key ways:
- Absence of adjacent liver parenchymal hyperemia and pericholecystic inflammatory changes on imaging 1
- Recurrent rather than continuous symptoms 4
- The gallbladder becomes thickened and fibrotic from repeated inflammation 1
- Diagnosis is difficult to make on imaging alone, as the gallbladder may appear contracted or normal 1, 3
Special Considerations in Elderly Patients
Middle-aged to elderly females represent the highest-risk population (female-to-male ratio 4:1 during reproductive years) 4:
- Atypical presentations: Atypical pain occurs in only 12% of elderly patients, and complete absence of pain is rare (5%) 1, 5
- Laboratory findings: Elderly patients may show higher WBC and CRP levels than younger patients, possibly due to more severe forms of disease 1
- Clinical manifestations: Despite theory suggesting lower responsiveness, elderly patients often present with overt clinical manifestations, particularly when gangrenous cholecystitis develops 1
Diagnostic Approach
When chronic cholecystitis is suspected based on symptoms:
- First-line imaging: Right upper quadrant ultrasound has 90-95% sensitivity for detecting gallstones, which are present in 95% of chronic cholecystitis cases 1, 5, 4
- If ultrasound is equivocal: MRCP has 85-100% sensitivity and 90% specificity for detecting cholelithiasis 1, 5
- Functional assessment: CCK cholescintigraphy (HIDA scan) has limited diagnostic value in acalculous chronic cholecystitis, as decreased ejection fraction does not reliably predict histologic features or clinical outcomes 6