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Context Long-standing diabetes mellitus results in autonomic nervous system dysfunction, leading to gastroparesis and cholecystoparesis. The latter can result in hydropic gallbladder, a condition that arises from the accumulation of mucinous secretions within the gallbladder, usually caused by obstruction of the cystic duct, but not in the case of the patients with diabetes that we have illustrated. Case report We describe three patients who presented with non-specific abdominal discomfort at the time of admission for complications of poorly controlled diabetes and were subsequently found to have hydropic gallbladder. We theorize that hydropic gallbladder may be a result of a natural progression of gallbladder dysfunction in poorly controlled diabetics with autonomic neuropathy. In our cases the risk of perioperative mortality was high at the time of presentation. No surgical intervention was performed except in one case with the most significant sized gallbladder, and underwent a temporizing cholescystostomy. Conclusions The development of hydropic gallbladder in patients with non-obstructed cystic ducts highlights the complexities of management of patients with functional biliary pain. The rome committee on functional biliary and pancreatic disorders has defined the characteristics of this pain. There is a need for guidelines to direct appropriate assessment of hydropic gallbladder in diabetics and also to determine the indications for cholecystectomy.