Elective cholecystectomy was performed in 60 patients with biliary colic and acaiculous gallbladders during a 5-year period. Gallbladder wall disease was significantly more common (p < 0.01) in patients with acalculous gallbladders than in a similar symptomatic group with calculous gallbladders. Thirty-four of 43 patients (77%) available for long-term follow-up reported complete symptom relief after cholecystectomy. Preoperative ultrsonography, biliary scintigraphy, oral choiecystography, upper gastrointestinal series, and pathologic features of the gallbladder were equivocal in predicting long-term symptom relief. In patients with acalculous biliary colic, the best predictor of complete symptom relief is an adequate history of true biliary colic.