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AFHSB Surveillance Case Definitions

FINAL September 2016

Case Definition and Incidence Rules

For surveillance purposes, a case of gallbladder disease (cholecystitis, cholelithiasis and other

diseases of the gallbladder and biliary tract) is defined as:

 One hospitalization with a case defining diagnosis of gallbladder disease (see ICD9 and

ICD10 code lists below) in the primary diagnostic position; or

 Two outpatient medical encounters with a case defining diagnosis of gallbladder disease

(see ICD9 and ICD10 code lists below) in the primary diagnostic position.

For surveillance purposes, a case of cholecystectomy defined as:

 One hospitalization with a procedure (PR) code for cholecystectomy (see ICD9 and

ICD10 code lists below) in any position; or

 One outpatient medical encounter with a Current Procedure Terminology (CPT) code

for cholecystectomy (see CPT code list below) in any position.

Incidence rules:

For individuals who meet the case definition:

 For gallbladder disease and cholecystectomy, the incidence date is considered the date

of the first hospitalization or outpatient medical encounter that includes the defining

diagnosis or procedure code.

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GALLBLADDER DISEASE

Includes Cholecystitis, Cholelithiasis, Other Diseases of the Gallbladder and Biliary Tract

and Cholecystectomy

Background

This case definition was developed by the Armed Forces Health Surveillance Branch (AFHSB) for the

purpose of epidemiological surveillance of gallbladder disease and cholecystectomies.

Clinical Description

Irritation and inflammation of the gallbladder is known as cholecystitis. The most common cause of

cholecystitis is cholelithiasis (gallstones). Gallstones impede the release of bile from the gallbladder

which may trigger an acute “gallbladder attack” characterized by abdominal pain, bloating, nausea and

vomiting. When individual symptoms become frequent, recurrent, or severe, laparoscopic

cholecystectomy (i.e., surgical removal of the gallbladder) is usually indicated. Common non-

modifiable risk factors for gallstone development include female gender, age over 40, family history

and Native American or Mexican-American decent. Modifiable risk factors include obesity, high fat

or high-cholesterol diet, and diabetes.

Armed Forces Health Surveillance Branch. Gallbladder Disease and Cholecystectomies, Active

Component, U.S. Armed Forces, 2004-2013. Medical Surveillance Monthly Report (MSMR); 2014 Jun;

Vol 21(6): 8-11.

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