The term chronic cholecystitis has been used to denote nonacute symptoms caused by the presence of gallstones. A better term is biliary pain (also misnamed biliary colic), be-cause on1y a loose correlation exists between the presence of symptoms and pathologic findings such as inflammation in the gallbladder wall. Gallbladders from symptomatic patients may be grossly normal with mild histologic inflammation and may show fibrosis and thickening, often as a result of previous at-tacks of acute cholecystitis. Symptoms arise from contraction of the gallbladder during transient obstruction of the cystic duct by gallstones. Biliary pain usually is a steady ache in the epigastrium or right upper quadrant, which comes on quickly, reaches a plateau of intensity over a few minutes, and begins to subside gradually over 30 minutes to several hours. Referred pain may be felt at the tip of the scapula or right shoulder. Nausea and vomiting may accompany biliary pain, whereas fever, leukocytosis, and a palpable mass (signs of acute chole-cystitis) are not evident. Attacks occur at variable intervals (days to years). Other symptoms such as dyspepsia, fatty food intolerance, bloating and flatulence, heartburn, and belching may occur in patients with gallstones; however, they are nonspecific and frequently occur in individuals with normal gallbladders.

Gallstones can be best demonstrated by ultrasonography (sensitivity and specificity > 95%). Oral cholecystography (sensitivity 90%, specificity 75%) is reserved for ensuring cystic duct patency in patients whom dissolution therapy or ex-tracorporeal shock wave lithotripsy is planned.

Laparoscopic cholecystectomy is the treatment of choice for recurrent biliary pain and may be accompanied by preopera-tive endoscopic or radiologic (transoperative) examination of the common bile duct for concomitant choledocholithiasis. Open cholecystectomy, which carries a mortality rate of less than 0.5 %, may be necessary because of difficulties encoun-tered during a laparoscopic procedure and in certain patients such as those with prior abdominal surgery who may have ad-hesions and those who may be obese. Surgery relieves symp-toms of biliary pain in virtually all patients and prevents devel-opment of future complications, such as acute cholecystitis, choledocholithiasis, and cholangitis. Alternative approaches to eliminating gallstones, including dissolution and fragmenta-tion, are less commonly used because of their lower efficacy, cost, and higher gallstone recurrence rate. Several reports and trials have suggested that the use of nonsteroidal anti-inflam-matory agents during biliary pain may provide adequate pain relief and decrease the rate of progression to acute cholecysti-tis.

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