Biliary Abnormality on Imaging During Lenvatinib Plus Hepatic Arterial Infusion Chemotherapy With Cisplatin for Hepatocellular Carcinoma: A Pilot Descriptive Study.

This study aimed to evaluate the effects of dietary composition, physical activity, and body mass index on gallbladder recovery time following food consumption and to identify alternative scan preparation strategies for patients unable to fast before abdominal ultrasound. A quasi-experimental study involving 26 participants was conducted using four ultrasound sessions under different conditions: consumption of each dietary item with and without moderate physical activity. Gallbladder wall thickness and volume were measured hourly following standardised ultrasound protocols. Measurement reliability was assessed using the intraclass correlation coefficient on 30 randomly selected scans reviewed by two independent observers. Recovery time significantly varied among meal types (χ²(2) = 18.42, p < .001), with wholemeal bread yielding the fastest and yogurt the slowest recovery. Physical activity significantly enhanced wall recovery (p = 0.002) but did not affect volume (p = 0.317). Body mass index showed no significant effect. Moderate and excellent intraclass correlation coefficients were achieved for gallbladder wall thickness (0.52) and volume (0.88), respectively. Wholemeal bread and postprandial physical activity serve as effective alternatives for ultrasound preparation when assessing gallbladder wall recovery. These findings promote patient-specific ultrasound protocols to improve diagnostic efficiency and comfort.

Neuroendocrine tumor of the gallbladder: An unusual location.

Acute cholecystitis is a common cause of emergency surgical admission, particularly among elderly and medically complex patients. Percutaneous cholecystostomy (PC) is frequently used as a minimally invasive treatment option for patients considered unsuitable for early cholecystectomy. However, factors associated with in-hospital mortality and the impact of radiologic disease burden after PC remain incompletely characterized. We conducted a retrospective single-center cohort study including consecutive adult patients who underwent image-guided PC for acute cholecystitis between January 2022 and December 2025. Clinical, laboratory, procedural, and radiologic variables were analyzed. Factors associated with in-hospital mortality were evaluated using multivariable logistic regression analysis. An exploratory radiologic severity score (RSS) was constructed using predefined imaging findings including pericholecystic fluid, gallbladder perforation, emphysematous cholecystitis, and gallbladder wall thickness ≥ 7mm. Associations between RSS and inflammatory response following PC were also assessed. A total of 266 patients were included (mean age 64.9 ± 17.1 years; 56.4% male). The overall in-hospital mortality rate was 7.5% (n = 20). Factors independently associated with in-hospital mortality included older age (OR, 2.06 per 10-year increase, 95% CI, 1.25-3.39), malignancy (OR, 9.19, 95% CI, 2.71-31.22), elevated LDH (OR, 1.86 per 100 U/L increase, 95% CI, 1.23-2.81), and higher post-procedural day-3 CRP levels (OR, 2.17 per 50mg/L increase, 95% CI, 1.32-3.55). The multivariable model demonstrated good discriminative performance in internal validation (cross-validated AUC: 0.895). Higher RSS values were associated with reduced CRP decline following PC (p = 0.041), suggesting slower inflammatory resolution. However, RSS was not significantly associated with mortality or hospital length of stay. In this retrospective cohort, in-hospital mortality after percutaneous cholecystostomy was primarily associated with baseline patient vulnerability and persistent early inflammatory response after the intervention. Radiologic disease burden appeared to correlate with inflammatory recovery rather than mortality. Given the retrospective design, limited number of mortality events, and lack of external validation, these findings should be considered exploratory and hypothesis-generating. Prospective multicenter studies are warranted to further validate these observations.

To evaluate the diagnostic performance of cystic artery colour Doppler ultrasound indices in differentiating acute from chronic cholecystitis and to assess their added value over clinical and grayscale findings. In this prospective study, 101 adults with clinically suspected cholecystitis underwent ultrasound before cholecystectomy. Grayscale features and colour Doppler measurements of cystic and hepatic artery peak systolic velocity and resistive index were recorded; histopathology was the reference standard. Logistic regression models using clinical and grayscale variables alone and then with cystic artery peak systolic velocity were evaluated with receiver operating characteristic analysis. In total, 33 patients had acute and 68 had chronic cholecystitis. Acute cholecystitis showed more abnormal grayscale features, including increased gallbladder size, wall thickening and pericholecystic change. Cystic artery peak systolic velocity was higher in acute than chronic disease (40.8 ± 14.9 vs 26.1 ± 15.5 cm/s; p < 0.001), as was hepatic artery peak systolic velocity (74.0 ± 24.4 vs 60.2 ± 22.4 cm/s; p = 0.006), whereas resistive index did not differ meaningfully. Cystic artery peak systolic velocity showed fair discrimination (area under the curve 0.78; cut-off 31.5 cm/s; sensitivity 0.91; specificity 0.71); hepatic artery peak systolic velocity performed more modestly (area under the curve 0.67). Adding cystic artery peak systolic velocity to a grayscale-only model produced negligible improvement in overall performance. Cystic artery peak systolic velocity is a useful adjunct for distinguishing acute from chronic cholecystitis when grayscale findings are equivocal, whereas resistive index adds little diagnostic value. Routine Doppler assessment is unlikely to change decisions when grayscale ultrasound is definitive.

Cases of gallbladder carcinoma containing poorly cohesive and signet-ring cell components are extremely rare, and their clinical characteristics remain unclear. We report a case involving a 70-year-old man who presented with fever and abdominal pain. Imaging at admission revealed diffuse gallbladder wall thickening and peritoneal metastatic nodules around the gallbladder, leading to a diagnosis of advanced gallbladder carcinoma; however, concurrent cholecystitis was suspected because of persistent fever and elevated inflammatory markers. The patient showed no response to antimicrobial therapy or gallbladder drainage, raising concern for tumor-associated inflammation and cancer-related pain. Bile cytology did not yield a definitive diagnosis; the patient showed unusually rapid enlargement of peritoneal metastases and died 2 months after presentation. Autopsy with immunohistopathological analysis confirmed advanced poorly differentiated gallbladder carcinoma with focal poorly cohesive and signet-ring cell features. This case illustrates that rare histological subtypes of gallbladder carcinoma may progress rapidly with extensive peritoneal metastatic nodules. Moreover, in such atypical variants of gallbladder carcinoma, early consideration of oncologic treatment is important while simultaneously controlling the infection.

ABSTRACTIntroductionLenvatinib plus pembrolizumab is a standard first‐line therapy for advanced renal cell carcinoma (RCC), and acute acalculous cholecystitis is a rare adverse event.Case PresentationA 60‐year‐old woman with metastatic TFE3‐positive non–clear cell RCC, classified as poor risk by the International Metastatic RCC Database Consortium (IMDC) criteria, started pembrolizumab plus lenvatinib after palliative radiotherapy for cervical spine metastasis. Lenvatinib was initiated at 8 mg and escalated to 12 mg, achieving tumor shrinkage. Nine days after starting cycle 4, she developed fever and right upper quadrant pain. Computed tomography demonstrated gallbladder distension and wall thickening without gallstones, consistent with acute acalculous cholecystitis. Lenvatinib was interrupted, and intravenous piperacillin/tazobactam was administered; her symptoms improved without drainage. Lenvatinib was resumed at 8 mg with pembrolizumab, and no recurrence occurred.ConclusionEarly recognition and temporary interruption of lenvatinib with antibiotics may allow cautious rechallenge.

Background: Laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic gallstone disease. However, operative difficulty and postoperative morbidity vary considerably. Preoperative prediction of difficult LC remains clinically important. Gallbladder wall thickness (GBWT), measured by ultrasonography, has been suggested as a potential predictor of surgical complexity. This study aimed to evaluate the association between preoperative GBWT and intra-operative as well as postoperative outcomes following LC. Methods: A prospective observational study was conducted over two years (2024–2026) at a tertiary care teaching hospital. Seventy-eight patients undergoing elective LC for cholelithiasis were included. GBWT was measured preoperatively using ultrasonography and patients were categorized into four groups: ≤2 mm (normal), &gt;2–4 mm (mild), &gt;4–6 mm (moderate), and &gt;6 mm (severe). Intra operative parameters (adhesions, bleeding, biliary injury, conversion to open surgery, operative time) and postoperative outcomes (bile leak, surgical site infection, cardiopulmonary complications, and hospital stay) were recorded. Statistical analysis was performed using chi-square test and ANOVA, with p &lt; 0.05 considered significant. Results: Forty-one percent of patients demonstrated gallbladder wall thickening (&gt;2 mm). Intra operative complications increased significantly with GBWT: 13.0% in normal, 50.0% in mild, 80.0% in moderate, and 100% in severe groups (p &lt; 0.001). Conversion to open surgery occurred in 2.2%, 11.1%, 30.0%, and 50.0% respectively (p &lt; 0.001). Postoperative complications rose proportionally (6.5%, 22.2%, 40.0%, 75.0%; p &lt; 0.001). Mean hospital stay increased from 2.8 ± 0.9 days in normal walls to 8.0 ± 1.4 days in severely thickened walls (p &lt; 0.001). Conclusion: Preoperative GBWT is a significant predictor of intra operative difficulty, conversion rate, postoperative morbidity, and prolonged hospital stay. GBWT ≥5 mm may serve as a practical threshold to anticipate difficult LC and guide operative planning

Gallstones (cholelithiasis) are common, with a significant portion of affected individuals developing acute cholecystitis, which can lead to severe complications. While ultrasound (US) is typically the first imaging method used, multidetector computed tomography (MDCT) may be better at detecting more complex scenarios. This study aimed to compare the detection of imaging features and complications of acute cholecystitis between US and MDCT in a cohort of confirmed cases, and to evaluate their complementary roles in clinical practice. A retrospective study was conducted including 134 adults with clinically suspected acute cholecystitis who underwent same-day US and MDCT, with subsequent confirmation by pathology or intervention. Two radiologists independently reviewed all imaging studies, and the detection of imaging features and complications was compared. US showed significantly higher detection rates than MDCT for gallbladder wall thickening (98.5% vs. 66.4%, P < 0.001), sludge (35.1% vs. 14.9%, P < 0.001), and pericholecystic fluid (75.4% vs. 47.8%, P < 0.001). Conversely, MDCT more frequently identified complications such as choledocholithiasis (8.2% vs. 2.2% by US, P = 0.041) and liver abscesses (6.7% vs. 1.5% by US, P = 0.035). MDCT also identified findings consistent with cholecystitis in 7 patients (5.2%) not detected by US and was associated with a change in management of 20 patients (14.9%). US remains effective as a first-line modality for detecting acute cholecystitis, while MDCT offers additional value in identifying complications and influencing management. Together, these findings support a complementary, rather than substitutive, role for the two modalities.

Complicated cholelithiasis remains a frequent challenge in emergency general surgery because acute severe cholecystitis, gallbladder empyema, gangrenous inflammation, dense adhesions, and Mirizzi syndrome may distort biliary anatomy and increase the risk of conversion, morbidity, and bile duct injury. This integrative literature review analyzed evidence on laparoscopic cholecystectomy in patients with complicated gallstone disease, focusing on surgical outcomes, technical difficulties, intraoperative and postoperative complications, conversion predictors, recovery time, and perioperative strategies. The reviewed literature indicates that early laparoscopic cholecystectomy is generally effective and safe when performed with strict adherence to operative safety principles, especially the Critical View of Safety and timely use of bailout strategies. Male sex, advanced age, delayed presentation, severe inflammation, gallbladder wall thickening, empyema, gangrene, Mirizzi syndrome, obesity, diabetes, and previous upper abdominal surgery are associated with greater operative difficulty and higher conversion risk. Subtotal cholecystectomy, fundus-first dissection, intraoperative imaging, conversion, and drainage should be considered safety measures rather than technical failure. Enhanced Recovery After Surgery protocols may reduce pain, nausea, length of stay, and functional delay when adapted to disease severity. Laparoscopic cholecystectomy remains the preferred approach in complex cholelithiasis when supported by surgical judgment, structured training, and individualized recovery pathways.

To identify the risk factors for acute cholecystitis (AC) in patients with asymptomatic gallbladder stone (AGS) and to establish a clinical prediction model. A descriptive study. Place and Duration of the Study: Department of Hepatobiliary and Pancreatic Surgery, Shaoxing Central Hospital, Shaoxing, China, from January 2023 to January 2025. A total of 43 AGS patients and 86 AC patients were enrolled. Univariate analysis identified clinically significant indicators, which were incorporated into a multivariate binary logistic regression model to construct a nomogram. The receiver operating characteristic (ROC) curve, calibration curve, concordance index (C-index), and decision curve analysis (DCA) were used to evaluate model performance. Univariate analysis showed higher blood glucose, gallbladder length/width, gallbladder wall thickness, gallbladder neck stones, sludge-like stones, and positive bile culture in the AC group (all p <0.05). Independent risk factors were identified by multivariate analysis, which included blood glucose ≥6.75 mmol/L, gallbladder width ≥30.5 mm, wall thickness ≥3.15 mm, gallbladder neck stones, and sludge-like stones (p <0.05). The calibration curve exhibited excellent consistency between the predictive model and actual clinical reality. The C-index was 0.905 (95% CI: 0.876-0.934), and the area under the curve (AUC) was 0.924 (95% CI: 0.880-0.967), confirming the model's excellent discriminative ability. Blood glucose ≥6.75 mmol/L, gallbladder width ≥30.5 mm, wall thickness ≥3.15 mm, gallbladder neck stone, and sludge-like stones serve as independent risk factors for AC in the AGS patients. This model exhibits good predictive performance and high clinical utility. Asymptomatic gallstone, Acute cholecystitis, Risk factors, Prediction model, AGS.

The exact techniques for the extraction of thick-walled gall bladder and large calculus during laparoscopic cholecystectomy are not well described. This may require to dilate the port site or to enlarge the incision size, which has its own complications. This is a description of a simple technique that helps in easy extraction of the thick-walled gall bladder and large stone more than 1 cm during laparoscopic cholecystectomy. These cases may require to dilate the port site or to enlarge the incision size, which can lead to increased operating time, more post-operative pain, increased port site hernia and infection risk. In this technique, gall bladder is longitudinally split along its long axis and large calculus, if present, is crushed in the endobag. This endobag with specimen can be removed easily from the 1 cm port site without need for the port site dilatation. We have employed 'longitudinal gall bladder splitting Technique' in around 245 cases of laparoscopic cholecystectomy operated in the past 5 years. Only three cases of port site infection and no cases of port site hernia were noted in this study. Ease of extraction by surgeons was rated as 9.6 on a scale of 1-10. 'Longitudinal gall bladder splitting Technique' is a simple and easily reproducible technique used for the extraction of thick-walled gall bladder and large calculus which reduces complications and makes it easy for the surgeon.

Gallbladder amyloidosis is an exceptionally rare condition that may clinically mimic extrahepatic cholestasis. An 81-year-old man presented with persistent cholestatic jaundice and recurrent right upper quadrant pain. Laboratory evaluation showed conjugated hyperbilirubinemia and elevated cholestatic liver enzymes without signs of inflammation. Imaging studies, including ultrasound, MRCP, and CT, demonstrated gallstones and gallbladder wall thickening but no bile duct dilation or obstruction. Endoscopic retrograde cholangiopancreatography and endoscopic ultrasound were unremarkable. Because of ongoing pain and cholestasis, laparoscopic cholecystectomy was performed. Histopathological examination revealed chronic fibrosing cholecystitis with marked submucosal and vascular deposition of amorphous eosinophilic material, showing apple-green birefringence under polarized light after Congo red staining, consistent with amyloid. Immunohistochemistry favored transthyretin (ATTR) amyloid deposition. Postoperatively, the patient recovered uneventfully with resolution of pruritus and normalization of bilirubin. Extensive systemic evaluation excluded generalized amyloidosis, indicating a localized form of gallbladder amyloidosis. This case underscores the importance of considering infiltrative diseases such as amyloidosis in the differential diagnosis of unexplained cholestatic jaundice, particularly when imaging fails to show mechanical obstruction. Recognition of this entity may prevent unnecessary invasive interventions and emphasizes the diagnostic value of histopathological confirmation following cholecystectomy.

The sonographic diagnosis of acute cholecystitis presents challenges. In our practice, we enhance diagnostic accuracy by determining a patient's risk of acute cholecystitis using four non-image parameters and five imaging parameters. The non-image risk assessment is based on patient age, sex, leukocytosis, and the presence of a sonographic Murphy sign. The imaging risk stratification is derived from evaluating gallbladder (GB) distention, GB wall thickness, GB contents, pericholecystic irregular collections, and hepatic artery peak systolic velocity (HAv). By applying a standardized scoring framework, patients are stratified into one of four diagnostic categories for acute cholecystitis: (1) practically excluded (< 1% probability); (2) reduced risk (< 10% probability); (3) elevated risk (25-30% probability); (4) substantially elevated risk (with three subgroups having 50%, 75%, and 90% probability). This review outlines the methodology of our approach, provides supporting data from published cohorts, and explains the macro-enabled Excel tool we use to streamline the analysis. This tool generates standardized report and impression statements that can be directly incorporated into radiology reporting templates. The approach promotes consistency in reporting, particularly amongst trainees formulating preliminary interpretations, and offers consistent evidence-based probability estimates to emergency department physicians and surgeons for clinical decision-making using a framework that eliminates indeterminate assessments.

Incidental findings (IFs) are findings on imaging studies obtained for indications unrelated to the IF. IFs may represent clinically important lesions such as malignancy. However, the vast majority are benign with no clinical relevance. IFs can lead to unnecessary follow-up imaging, procedures, and iatrogenic complications, resulting in significant financial and psychologic burden to patients and the health care system. To address this, the American College of Radiology released a series of white papers that provide management guidelines for a variety of IFs in different organs. Since the original white papers and subsequent updates were published, a wealth of research has been provided on various IFs that is either concordant with or contradictory to previous guidelines. Additionally, there are multiple common IFs that are not discussed in an existing white paper. The authors discuss updated evidence regarding common IFs for various topics including hepatic findings (hyperenhancing liver lesions at CT, echogenic liver lesions), biliary findings (asymptomatic biliary ductal dilatation, focal fundal gallbladder wall thickening, gallbladder polyps), renal findings (indeterminate homogeneous renal mass at CT, hyperechoic renal lesions, hyperintense renal lesions at T1-weighted MRI), adrenal nodules, splenic lesions, bowel and mesenteric findings (intussusception, misty mesentery), and male reproductive findings (testicular microlithiasis, isolated right-sided varicocele). The authors review recent literature that addresses existing white paper topics and common IFs that are not discussed in existing white papers. ©RSNA, 2026.

Laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic gallstone disease. Despite advances in technique and experience, LC may be technically difficult in a subset of patients, leading to increased operative time, complications, and conversion to open surgery. Preoperative prediction of difficult LC can improve surgical planning and patient counseling. In this study, we will evaluate the role of preoperative clinical and ultrasonographic parameters in predicting difficult laparoscopic cholecystectomy. This prospective observational study was conducted at a tertiary care teaching hospital over a period of 18 months. Eighty-two patients undergoing elective laparoscopic cholecystectomy were included. Preoperative clinical parameters and ultrasonographic findings were recorded and correlated with intraoperative difficulty. Difficult LC was defined based on operative findings, including difficulty in access, adhesiolysis, Calot’s triangle dissection, gallbladder dissection, and intraoperative bleeding. Difficult laparoscopic cholecystectomy was encountered in 28 patients (34.15%). Gallbladder wall thickness &gt;3 mm, stone size &gt;20 mm, multiple stones, body mass index (BMI) &gt;30 kg/m², pericholecystic collection, liver span &gt;13 cm, narrow subcostal angle, and xipho-umbilical distance &gt;18 cm showed a statistically significant association with difficult LC (p &lt;0.05). Conversion to open cholecystectomy was required in 11 patients (13.41%). Preoperative assessment using clinical and ultrasonographic parameters is useful in predicting difficult laparoscopic cholecystectomy and the likelihood of conversion to open surgery. This enables better operative planning, optimal resource allocation, and improved patient counseling.

Dengue is a mosquito-borne viral illness affecting children and can progress to severe forms with capillary leakage, bleeding and organ dysfunction. Early detection is crucial to reduce complications. This study evaluated the predictive value of 2 noninvasive markers, urine albumin-creatinine ratio (UACR) and gall bladder wall thickness (GBWT) for disease severity in pediatric dengue. A prospective observational study was conducted from May 2023 to November 2024 at a tertiary care hospital in Northern India. Children aged 6 months to 12 years with moderate to severe dengue (WHO 2009 classification) were included. UACR was measured from spot urine samples at admission, during deterioration or at discharge. GBWT was assessed via abdominal ultrasound between days 3 and 6 of fever. Associations with disease severity, laboratory parameters, and mortality outcomes were analyzed. Among 74 participants, mean UACR (mg/g) was significantly higher in severe dengue compared to moderate cases (136.31 [151.26] vs. 44.87 [59.77]; P < 0.001), with elevated UACR linked to higher mortality. Mean GBWT (mm) was significantly greater in severe dengue (7.35 [2.25] vs. 5.11 [2.49]; P = 0.035), correlating with poor outcomes. Sensitivity and specificity of UACR (cutoff 30 mg/g) were 62% and 60%, and GBWT at 5 mm were 81% and 60%. Odds ratios for severe dengue were 3.9 (UACR), 10.7 (GBWT) and 13.3 (both). Honeycomb GBWT patterns were more frequent in fatal cases. UACR and GBWT, while not definitive alone, are noninvasive adjuncts for predicting severity and mortality in pediatric dengue, supporting early identification, triage and management.

Laparoscopic cholecystectomy is the standard surgical treatment for benign gallbladder disease; however, a substantial proportion of procedures are classified as difficult due to anatomical distortion, inflammation, or technical factors, resulting in increased operative complexity and higher complication rates. This literature review aims to synthesize current evidence regarding predictive factors, classification systems, surgical strategies, and clinical outcomes associated with difficult cholecystectomy. A systematic search was conducted in PubMed (Medline), Scopus, Web of Science, SciELO, and Google Scholar for studies published from 2010 and 2025 in English or Spanish addressing difficult cholecystectomy, predictive factors, classification systems, surgical approaches, and outcomes. The literature consistently identifies advanced age, male sex, obesity, comorbidities, previous abdominal surgery, acute cholecystitis, elevated inflammatory markers, and ultrasonographic findings such as gallbladder wall thickening and impacted stones as key predictors of difficult cholecystectomy. Classification systems including the Tokyo Guidelines, Nassar scale, Parkland grading, and G10 scoring system demonstrate high predictive value for operative difficulty, conversion, and complications. Bailout strategies such as subtotal laparoscopic cholecystectomy, fundus-first technique, and timely conversion to open surgery are associated with improved safety in complex cases. Early identification of predictive factors and systematic use of validated classification systems are essential to optimize surgical planning, reduce complications, and improve patient outcomes in difficult cholecystectomy.

Background Percutaneous cholecystostomy (PC) is commonly utilized in high-risk patients with acute cholecystitis as either a bridge to surgery or as definitive therapy. However, early recurrence following tube removal remains a significant clinical concern. This study aimed to identify imaging predictors associated with early recurrence after PC tube removal. Methods A total of 1,002 patients who underwent PC between 2008 and 2024 were retrospectively reviewed. Patients who subsequently underwent cholecystectomy (n = 606), were discharged with the tube in place (n = 221), or did not undergo fluoroscopic tube removal (n = 21) were excluded, resulting in 154 patients for analysis. Pre-removal imaging (CT or ultrasound) was assessed for gallbladder wall thickening, pericholecystic fluid, residual stones or sludge, and cystic duct stricture. The primary outcome was recurrence within 30 days of tube removal. Cox proportional hazards models were utilized for analysis. Results Early recurrence occurred in 10 patients (6.5%). Cystic duct stricture on fluoroscopy was significantly more frequent in the recurrence group compared with the non-recurrence group (50.0% vs 6.9%, p < 0.001). In multivariate Cox proportional hazards analysis, cystic duct stricture (HR = 17.59, 95% CI 4.19–73.86, p < 0.001) and pancreatobiliary malignancy (HR = 9.34, 95% CI 1.56–56.04, p = 0.01) were identified as independent predictors of early recurrence. Conclusion Cystic duct stricture identified on fluoroscopic cholangiography represents a strong independent radiologic predictor of early recurrence following PC tube removal, and pancreatobiliary malignancy further contributes to elevated recurrence risk.

ABSTRACTObjective:Acute calculous cholecystitis is one of the most common surgical infectious disease emergencies worldwide. Early laparoscopic cholecystectomy (LC) is the definitive treatment, but severe inflammation often leads to technical difficulty and increased intraoperative adverse events. This study evaluated preoperative gallbladder wall thickness (GWT) on ultrasound as a simple, objective predictor of difficult LC in acute calculous cholecystitis.Methodology:A prospective cross-sectional study was conducted in the Department of Surgery, Aga Khan University Hospital, Karachi, from May to November 2022. Consecutive adult patients (18–60 years) with ultrasound-confirmed acute calculous cholecystitis undergoing LC within 96 hours of symptom onset were included (n=116). GWT was classified as normal (≤3 mm), moderate (3.1–7 mm), and severe (>7 mm). Intraoperative adverse events recorded were operative time >90 minutes, distended gallbladder requiring aspiration, dense adhesions, conversion to open procedure, and drain placement.Results:Mean GWT was 3.44 ± 1.79 mm. Severe thickening (>7 mm) was present in six patients (5.2%) and was highly significantly associated with prolonged operative time (p<0.001), need for gallbladder aspiration (p<0.001), conversion to open cholecystectomy (p<0.001), and subhepatic drain placement (p<0.001). Dense adhesions showed a strong trend (p=0.069).Conclusion:Severe preoperative gallbladder wall thickening (>7 mm) is a powerful, reproducible marker of intense inflammation and can predicts difficult laparoscopic cholecystectomy in acute infectious cholecystitis. Routine reporting of GWT allows accurate risk stratification, facilitates early involvement of experienced surgeons, reduces conversion rates, and optimizes outcomes in this common infectious surgical emergency – making it a practical and cost-effective surgical solution, especially in low-middle-income settings.