Gangrenous cholecystitis (GC) is a severe form of acute cholecystitis associated with complications such as perforation, sepsis, and increased mortality. Accurate preoperative identification of GC can influence management decisions. While computed tomography (CT) is commonly used to evaluate complicated cholecystitis, the relative diagnostic value of individual CT features for detecting histopathologically confirmed GC has been uncertain. This systematic review and meta-analysis sought to quantify associations between specific CT findings and GC and to summarize diagnostic performance for preoperative assessment.
The review searched PubMed, Web of Science, Ichushi-Web, and the Cochrane Central Register of Controlled Trials from inception to March 1, 2026, and additionally screened Google Scholar for eligible studies. Eligible studies enrolled patients with acute cholecystitis who underwent CT and had gangrenous cholecystitis confirmed by histopathology. Two reviewers independently screened studies, extracted data, and assessed methodological quality using the QUADAS-2 tool.
For pooled effect estimates, odds ratios (ORs) were calculated using a DerSimonian–Laird random-effects model. When 2 × 2 diagnostic contingency data were available, pooled sensitivity and specificity were estimated with a bivariate random-effects model fitted by restricted maximum likelihood (REML), from which positive and negative likelihood ratios and confidence intervals were derived. Sensitivity analyses examined model stability with respect to assumed between-study correlation and the influence of individual studies.
Ten retrospective studies met inclusion criteria, comprising a total of 786 patients, of whom 310 had histopathologically confirmed GC and 476 had non-gangrenous acute cholecystitis. Eight studies (724 patients; 268 GC and 456 non-GC) contributed data to the quantitative synthesis; two studies were included in qualitative synthesis only.
Three CT features were identified as strongly associated with GC in pooled analyses:
Absent gallbladder wall enhancement: pooled OR 10.23 (95% CI 5.67–18.46), indicating a strong association between lack of enhancement and histopathologic gangrenous change.
Wall irregularity: pooled OR 10.26 (95% CI 5.80–18.17), similarly indicating a strong association between irregular gallbladder wall appearance on CT and GC.
Pericholecystic inflammatory changes (pericholecystic stranding): pooled OR 4.82 (95% CI 1.76–13.24), representing a more modest but statistically significant association.
These pooled ORs reflect relative odds of GC when each imaging finding is present versus absent across the included retrospective surgical cohorts.
When pooled sensitivity and specificity could be estimated, the two findings with the most clinically relevant diagnostic metrics were absent wall enhancement and wall irregularity.
Absent wall enhancement: sensitivity 0.49, specificity 0.91, positive likelihood ratio 5.65. This profile indicates high specificity but only moderate sensitivity, so absent enhancement is reasonably specific for GC but misses many cases when absent.
Wall irregularity: sensitivity 0.43, specificity 0.94, positive likelihood ratio 7.14. Like absent enhancement, wall irregularity had high specificity and moderate-to-low sensitivity, favoring its use to rule in GC rather than to exclude it.
Confidence intervals for these estimates overlapped, and the pooled findings were not derived from direct within-study head-to-head comparisons of these imaging signs.
Pooled estimates for the associations and diagnostic metrics were reported to be robust to variations in the assumed between-study correlation within the bivariate model and to the omission of individual studies in sensitivity analyses. The authors therefore judged the pooled results stable within the limits of available data from the included retrospective cohorts.
Important limitations of the available evidence were highlighted:
All included studies were retrospective and drawn from surgically treated populations, which may introduce selection bias and limit generalizability to unselected patients presenting with suspected acute cholecystitis.
CT findings were not compared directly within studies, limiting the ability to rank diagnostic features by comparative performance.
Sensitivity was moderate for the most specific findings, meaning that absence of CT signs does not exclude GC.
Because of these limitations, the authors considered the results hypothesis-generating. They recommended prospective validation of the identified CT findings in unselected patients undergoing CT for suspected acute cholecystitis before these imaging signs are adopted as definitive preoperative diagnostic criteria.
This systematic review and meta-analysis found that absent gallbladder wall enhancement, gallbladder wall irregularity, and pericholecystic inflammatory changes on CT are associated with histopathologically confirmed gangrenous cholecystitis. Absent enhancement and wall irregularity combined high specificity with moderate sensitivity, suggesting they may help identify patients with a high probability of GC preoperatively but cannot reliably exclude the diagnosis when absent.
Given that the evidence comes from retrospective, surgically treated cohorts and that imaging signs were not directly compared within studies, prospective studies in broader clinical populations are needed to validate these CT features and to determine their role in clinical decision-making for suspected acute cholecystitis.
Conflict of interest and reporting notes: the authors declared no competing interests, noted use of ChatGPT for language editing during manuscript preparation, and reported that this review analyzed previously published data without new human or animal research.