High visceral adiposity and low skeletal muscle mass independently predict the development of acute cholecystitis in patients with gallstones. The study included 622 adult patients with cholelithiasis who were followed up on CT scans from 2015 to 2025. Patients with acute cholecystitis had significantly higher visceral fat area (VFA) and lower skeletal muscle index (SMI) compared to the control group. Independent predictors of the development of acute cholecystitis were hypertension (OR: 2.71), hyperlipidemia (OR: 2.88) and an increase in VFA of 10 cm² (OR: 1.34). A unit increase in SMI had a protective effect (OR: 0.94). The predictive model had strong discriminatory power with an AUC value of 0.857. The results show that body composition analysis by CT is useful in stratifying the risk of acute cholecystitis in patients with gallstones.