**3. Clinical manifestation**

It is generally assumed that approximately more than half of all patients with gallstones are asymptomatic in the natural history. The remaining patients may have intermitted histories of biliary colic pain, or presenting with acute cholecystitis, symptom following to choledocholithiasis or gall stone pancreatitis. Of them, only small percentages of patients with symptomatic gallstone disease developed serious complication within a certain period [4]. One of potential risks of patients with gallstone disease is the development of gallbladder carcinoma [5, 6].

#### **3.1 Acute cholecystitis**

Acute inflammation of the gallbladder is the most frequent complication of gallstone disease. The initiating factor is the stone impaction either cystic duct or in the infundibulum of the gallbladder. It is frequently explored for intraabdominal emergency, in particularly in middle-aged women and in the elderly. Approximately more than 50% of patients with acute cholecystitis have been bacteria in the bile culture, but these factors are thought to play a secondary role in the pathogenesis of cholecystitis. Bacteria typically isolated are of enteric origin, with the most common species being, *Escherichia coli*. Other bacteria may be present include Enterobacter, Klebsiella, or Enterococcus. Morphological changes of acute cholecystitis include, edema, hypervascularity, venous congestion, gallbladder distension.

#### **3.2 Chronic cholecystitis**

Whereas bacteria can be cultured from the bile of approximately more than 50% of patients with acute cholecystitis, the incidence of positive bile cultures in patients with chronic cholecystitis is less than 20%. In patients who have had recurring biliary colic pain with long-term gallstones, some of them had fibrosis and small round cell infiltration with the gallbladder wall thickening. Some patients with recurring biliary colic pain are thought histologically to have chronic cholecystitis.
