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Ultrasound of the gallbladder
Samir Haffar M.D.
Assistant Professor of Gastroenterology
Ultrasound of the gallbladder
 Normal GB ultrasound
 Congenital abnormalities
 GB stones & sludge
 Acute cholecystitis & its complications
 Chronic cholecystitis
 Polyps & adenomyomatosis
 GB carcinoma
 Miscellaneous: volvulus – nonvisualization
 Normal GB ultrasound
Anatomy of the gallbladder
Sherlock S & Dooley J. Diseases of the liver and biliary system.
Blackwell Science, Oxford, UK, 11th edition, 2002.
Normal ultrasound of gallbladder
Minimum 6 hours of fasting
Subcostal or intercostal scanning
Supine – LLD – Prone – Erect
GB wall ≤ 3 mm Anterior wall
Long-axis
Perpendicular
Transverse diameter < 4 cm
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
F
B
N
Gallbladder folds
Abraham D et al. Emergency medicine sonography: Pocket guide.
Jones & Bartlett Publishers, Boston, MA, USA, 1st edition, 2010.
Longitudinal view of gallbladder
Hartman’s pouch
Phrygian cap
Gallbladder folds
Phrygian cap (fundus over body)
Fold between neck & body
Sigmoid GB (multiple folds)
Acoustic shadow from a GB fold
Part of a fold within gallbladder producing an acoustic shadow
When only part of fold is visualized, it may mimic a polyp or a stone
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Edge refraction shadow
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Shadow near neck of GB on longitudinal section
Absence of visible stone at origin of shadow
Scanning in different positions
Proximal cystic duct
Longitudinal view of GB neck & proximal cystic duct
Serrated appearance of cystic duct secondary to valves of Heister
Occasionally identified on sonography
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Distal cystic duct
Normal distal cystic duct entering the CBD posteriorly
Parulekar SG. Ultrasound Quarterly 2002 ; 18 : 187 – 202.
 Congenital abnormalities
Congenital abnormalities of the gallbladder
• Agenesis of gallbladder Confirmation with other tests
• Anomalous GB location Abnormal locations
• Duplication of gallbladder One or two cystic ducts
• Septated gallbladder Honeycomb appearance
• Gallbladder diverticulum Any location in gallbladder
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Congenital anomalies of the gallbladder
Yamada T et all. Textbook of gastroenterology.
Wiley-Blackwell, Oxford, UK, 5th edition, 2009.
Septated GBDuplicated GB Diverticulum
Agenesis of gallbladder
1 in 6,000 live births – fewer than 300 reported cases
Waller AH et al. Clin Gastroenterol Hepatol 2008 ; 6 : 38.
• First described by Lemery in 1701
• Failure of cystic bud to develop in fourth week of life
• Associated with chromosomal abnormalities
• Symptoms attributed to biliary dyskinesia
• US diagnosis: absence of gallbladder
• HIDA scan: acute cholecystitis
Diagnosis usually obtained after surgical exploration
Agenesis of gallbladder
Waller AH et al. Clin Gastroenterol Hepatol 2008 ; 6 : 38.
HIDA scan
Uptake by liver
Excretion into CBD & bowel
No visualization of gallbladder
MRI & MRCP
No visualization of normal or
ectopic GB
Normal biliary tree
Anomalous location of gallbladder
Rare – Reported only in isolated case reports
Most common locations
• Left side (posterior to left lobe)
• Intrahepatic
• Suprahepatic (right lobe & diaphragm)
• Retrohepatic (posterior to right lobe)
Intrahepatic GB
May preclude Lap surgery
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Duplication of gallbladder
One in 3000 to 4000 GB
2 gallbladders adjacent to each other with 2 separate cystic ducts
After meals, both gallbladders showed normal emptying
www.ultrasound-images.com/gall-bladder.htm
Multi-septate gallbladder
Congenital origin – Very rare
• Entire GB or part of lumen
• Chambers communicate by orifices
• Isolated or coexist with other anomalies
• Symptoms of recurrent cholecystitis
• Multiple linear fine echogenic septations
Oriented horizontally or vertically
Kapoor V et al. J Ultrasound Med 2002 ; 21 : 677 – 680.
True diverticulum of gallbladder
Extreme rarity
Occurs anywhere in GB
Usually single
Varies greatly in size
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
 Gallbladder stones & sludge
US of gallbladder stone
Gold standard for diagnosis of cholelithasis
3 sonographic criteria
• Echogenic focus
• Cast acoustic shadow
• Seek gravitational dependence
Stones < 2 – 3 mm may be difficult to visualize
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
Shadow of gallbladder stone
* Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
** Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.
3 patterns of shadowing*
 Clean shadow Solitary stone
 Confluent shadowing Multiple small stones
 Wall-Echo-Shadow (WES) GB filled with gallstones
** Soft pigment stones may not shadow
Confluent shadowing of GB stones
Multiple small stones gravel abut each other with confluent AS
Mural thickening of gallbladder
Acoustic shadow of a gallbladder stone
Time gain compensation
too high
Time gain compensation
is lower
Bates J A. Abdominal Ultrasound: How, why and when.
Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
Stone smaller
than the beam
Shadowing of the stones
Shadow
Bates J A. Abdominal Ultrasound: How, why and when.
Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
Stone occupies
width of the beam
Large stone
outside focal zone
Large stone
just out of beam
No shadow
Floating stones
Bates J A. Abdominal Ultrasound: How, Why and When.
Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
Floating stones just below anterior gallbladder wall
Tissue harmonic imaging & gallstones
Longitudinal ultrasound
Normal gallbladder
Rubens D. Radiol Clin North Am 2004 ; 42 : 257 – 78.
Harmonic imaging
Multiple small stones
Correct & incorrect positions for prone scanning
Demonstrates gravitational dependence of stone
Correct: transducer as vertically as possible to image anterior GB wall
Incorrect: most dependent anterior part of GB not well examined
Hough DM et al. J Ultrasound Med 2000 ; 19 : 633 – 638.
Pitfalls in diagnosis of GB stone
Residue in bowel indenting posterior wall of GB
mimics gallstones
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Dependent debris in the gallbladder
• Sludge
• Pseudosludge
• Blood
• Pus
• Milk of calcium bile
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Biliary sludge
Prevalence unknown in general population
• Predisposing factors Pregnancy
Rapid weight loss & prolonged fasting
Long-term TPN
Ceftriaxone – Prolonged octreotide tt
Bone marrow transplantation
• Evolution (3 years) 50% resolve spontaneously
20% persist asymptomatically
5 – 15 % develop gallstones
10 – 15 % become symptomatic
• Complications Biliary colic, AAC, pancreatitis
Biliary sludge
Also known as biliary sand
Low-amplitude nonshadowing echoes in dependent portion of GB
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
Occasionally, sludge can be highly echogenic
Pseudosludge
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Most commonly along posterior surface of gallbladder
Produced by “sidelobe artifacts”
Disappear in different positions & when central portion of GB scanned
Aggregated sludge – Sludge ball
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Change in appearance or disappearance on follow-up
Differentiates sludge ball from a stone or neoplasm
Nonshadowing mobile echogenic structures
Aggregated sludge – Tumefactive sludge
GB with tumor-like sludge
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Potential mobility of sludge
Normal gallbladder wall
No vascularity detected on Doppler US
Follow-up
Biliary sludge
"hepatization" of gallbladder
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.
Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
GB entirely filled with sludge isoechoic to adjacent liver
Recognized by identifying normal GB wall
Blood in the gallbladder
Clinical history very useful for diagnosis
Sonographic findings
• Echogenic or mixed echogenicity
• Fluid with low-level internal echoes
• Retractile
• May be mobile
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Angled edges of clot
Quite typical of blood clots
Milk of calcium bile (limey bile)
Diagnosis can be confirmed by abdominal radiography or CT
High-attenuation material within
dependent portion of GB
Highly echogenic material in
dependent portion of GB with AS
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Milk of calcium bile (limey bile)
Abdominal radiography
 Acute cholecystitis & its complications
Causes of right upper quadrant pain
• Peptic ulcer disease
• Pancreatitis
• Hepatitis
• Appendicitis
• Hepatic congestion from right-sided heart failure
• Perihepatitis (Fitz-Hugh-Curtis syndrome)
• Right lower lobe pneumonia
• Right-sided pyelonephritis
• Nephro-ureterolithiasis
Diagnostic standard for acute cholecystitis
Tokyo guidelines 2007
Hirota M et al. J Hepatobiliary Pancreat Surg 2007 ; 14 : 78 – 82 .
Three categories of diagnostic findings
One criterion from each category must be fulfilled
(1) Murphy sign or pain/tenderness in RUQ or RUQ mass
(2) Fever, leukocytosis, or elevated CRP
(3) Confirmation by US or HIDA scan
Acute cholecystitis – HIDA scan
Higher accuracy than ultrasonography
Talley NJ et al. Practical gastroenterology & hepatology: Liver & biliary disease.
Wiley Blackwell, Oxford, UK, First edition, 2010.
Tracer in GB
Tracer in CBD
Tracer in small bowel
GB
CBD
Small
bowel
Normal HIDA scan
Non-filling of GB
Tracer in CBD
Tracer in small bowel
CBD
Small
bowel
Acute cholecystitis
Sonographic findings in acute cholecystitis
• Impacted stone in cystic duct or GB neck
• Positive sonographic Murphy's sign
• Thickening of GB wall (>3 mm)
• Distention of GB lumen (> 4 cm)
• Pericholecystic fluid collections (frequent)
• Hyperemic GB wall on color Doppler (supportive test)
None of above signs pathognomonic
Combination of multiple signs make correct diagnosis
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Acute cholecystitis
Caused by gallstones in more than 90% of cases
Large obstructing stone within GB neck
Thick hypoechoic gallbladder wall
Positive sonographic Murphy sign
Ralls PW et al. Gastroenterol Clin N Am 2002 ; 31 : 801–825.
Negative sonographic Murphy’s sign
• Patients who received pain medicine or steroids
• Para or quadriplegic patients
• Patients not able to give reliable history or pain response
• Denervated GB: DM – gangrenous cholecystitis
• Gallbladder rupture
Careful attention to clinical status important
when assessing for sonographic Murphy‟s sign
Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.
Gallbladder wall thickening
• Generalized edematous states CHF – Renal failure
End-stage cirrhosis
Hypoalbuminemia
• Inflammatory conditions Primary Acute cholecystitis
Chronic cholecystitis
Cholangitis
Secondary Acute hepatitis
Perforated DU
Pancreatitis
Diverticulitis/colitis
• Neoplastic conditions Adenocarcinoma – Metastases
• Miscellaneous Adenomyomatosis – Varices
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Diffuse gallbladder wall thickening
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Three echo patterns (not specific)
 Uniformly echogenic pattern
 Central hypoechoic zone & 2 peripheral echogenic layers
 Striated pattern
Gallbladder wall thickening
Uniformly echogenic pattern
Echogenic thickening of the wall in chronic cholecystitis
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Gallbladder wall thickening
Central hypoechoic zone separated by two echogenic layers
Gallbladder wall thickening due to ascites
Gallbladder wall thickening
Striated pattern
Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.
Striated wall with alternating echogenic & hypoechoic layers
Striated wall in setting of acute cholecystitis: gangrenous cholecystitis
Striated wall without evidence of acute cholecystitis: non specific
Gallbladder wall thickening
Rubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 – 413.
Gallstones
Focal GB wall thickening (7 mm)
Free air with reverberation shadows
Pericholecystic fluid (arrows)
Free air (arrowheads)
Extraluminal air (paired arrowheads)
Peptic ulcer perforation
Gallbladder wall thickening
Rubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 – 413.
Focal pyelonephritis
Heterogeneous decreased
attenuation area typical
of focal pyelonephritis
GB wall thickening 3-cm echogenic mass
in lower pole of rt kidney
Pericholecystic fluid
Two specific patterns
Type I Thin anechoic crescent-shaped collection
adjacent to gallbladder wall
Nonspecific finding
Type II Round or irregularly shaped collection with
thick walls, septations, or internal debris
Associated with GB perforation & abscess
Teefey SA et al. J Ultrasound Med 1991 ; 10 : 603 – 6.
Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.
Acute cholecystitis
Hyperemic GB wall
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Color Doppler sonography
Increased vascularity in GB wall
Supportive test
Acute acalculous cholecystitis (AAC)
5 – 15% of acute cholecystitis
• Critically ill patients Major surgery
Severe trauma
Sepsis
Total parenteral nutrition
Diabetes
Atherosclerotic disease
HIV infection
• Nonhospitalized patients Elderly male with atherosclerosis
HIDA scan & sampling of luminal contents
help to establish the diagnosis
Acute acalculous cholecystitis (AAC)
Difficult to diagnose clinically & on imaging
Marked GB mural thickening
Hypoechoic regions within wall
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
Marked GB mural thickening
with hypo & hyperenhancing areas
Complications of acute cholecystitis
• Suppurative cholecystitis (empyema)
• Gangrenous cholecystitis Up to 20%
• Emphysematous cholecystitis 1 %
• Hemorrhagic cholecystitis Rare
• Gallbladder perforation 5 – 10%
Suppurative cholecystitis (Empyema)
Patients very ill with fever & acute pain
Fine echoes caused by pus in bile
Pericholecystic GB collection (leakage)
US used to guide drainage before surgery
Bates J A. Abdominal Ultrasound: How, why and when.
Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
Large GB full of pus & stones
Gangrenous cholecystitis
No specific diagnostic US findings
• Striated thickening of GB wall
• Intraluminal membranes (5%)
• Marked asymmetry of GB wall
• Echogenic debris within GB
• Pericholecystic fluid collections
• US Murphy’s sign negative in 70%
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
Mucosal sloughing
Echogenic debris within GB
Gangrenous cholecystitis
Mucosal sloughing
Rubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413.
Longitudinal US of gallbladder
Intraluminal membranes associated gallbladder gangrene
Stone impacted in gallbladder neck
Emphysematous cholecystitis
Prompt surgical intervention required
• Organisms Clostridium welchii & Escherichia coli
• Characteristics Male preponderance (70%)
Frequent occurrence in diabetic (50%)
Lack of gallstones in up to one third
Higher risk of gangrene & perforation
• Three stages Stage 1: Gas in GB lumen
Stage 2: Gas in GB wall
Stage 3: Gas in pericholecystic tissues
Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216.
Appearance depends on amount of gas present
Emphysematous cholecystitis
Associated with DM & atherosclerotic disease
Intraluminal & intramural gas bubbles
Debris within necrotic GB
Higher sensitivity of CT
for the diagnosis
Diagnosis should be confirmed by abdominal radiography or CT
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
Emphysematous cholecystitis
Small amount of gas
Supine position
Presence of echoes anteriorly
Could be in the lumen or the wall
Rubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413.
Upright position
Gas moves & breaks into bubbles
Distinguishing it from calcium
Emphysematous cholecystitis
Large amount of gas
Absence of a normal gallbladder is a clue
Gas in GB completely obscures the lumen (dirty shadow)
Bates J A. Abdominal Ultrasound: How, Why and When.
Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
Location of GB fossa essential to avoid mistaking this for bowel gas
Emphysematous cholecystitis
Abdominal radiography
Intraluminal & intramural gas bubbles
Bates J A. Abdominal Ultrasound: How, Why and When.
Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
Gallbladder perforation
5 – 10 % of patients with acute cholecystitis
Small defect in GB wall: not always seen
Deflation of the gallbladder
Pericholecystic fluid collection
Pericholecystic abscess
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.
Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
Disruption of GB wall
GB perforation – Pericholecystic abscess
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.
Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
Abscess (internal strands typical of abscess)
Echogenic inflamed fat
Small amount of ascites
Hemorrhagic cholecystitis
Rare – Atherosclerosis – High mortality rate
Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216.
Echogenic material with higher
echogenicity than sludge
Increased density of bile
Hemorrhagic cholecystitis
Differential diagnosis
• Blood in gallbladder Neoplasm
Aneurysms
Trauma
Anticoagulation
Ectopic pancreas
Ectopic gastric mucosa
• High-density bile Recently administered IV contrast
Milk of calcium bile
Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216.
 Chronic cholecystitis
Forms of chronic cholecystitis
• Traditional chronic cholecystitis
Thick gallbladder wall with gallstones
• Wall-Echo-Shadow complex (WES)
Double arc-shadow sign
• Porcelain gallbladder
High incidence of GB carcinoma (10 – 30%)
• Xanthogranulomatous cholecystitis (XGC)
Difficult to distinguish from adenomyomatosis &
gallbladder carcinoma
Chronic cholecystitis
Bates J A. Abdominal Ultrasound: How, Why and When.
Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
Thick gallbladder wall
Small gallbladder stone with posterior AS
Bouts of acute cholecystitis may complicate chronic cholecystitis
Wall-Echo-Shadow complex (WES)
Contracted gallbladder filled with stones
2 parallel arcuate hyperechoic lines
Separated by thin hypoechoic space
Distal acoustic shadowing
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
Differentiation from air or calcification in GB wall
Normal GB wall not seen; only bright echo & AS seen
Porcelain gallbladder
Calcified wall with acoustic shadow
Mistaken for stone within GB lumen
No GB wall visible
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.
Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
Dense calcification in GB fundus
Porcelain gallbladder – Mild calcification
Rickes S et al. N Engl J Med, 2002 ; 346 : e4.
Computed tomography
Gallstones
Calcification of GB wall
Ultrasonography
Gallstones (one in cystic duct)
leading to GB enlargement (5 cm)
Calcification of GB wall
Porcelain gallbladder
Abdominal radiography
Xanthogranulomatous cholecystitis (XGC)
2% of cholecystectomy specimens
Compressed lumen
Multiple large mural nodules
separated by enhancing margins
Stone not visualized
Compressed lumen
Multiple hypoechoic mural nodules
Wall markedly thickened
Adjacent stone
Rubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413.
 GB polyps & adenomyomatosis
Classification of gallbladder polyps
3 – 7% of subjects undergoing US
Gallahan WC et al. Gastroenterol Clin N Am 2010 ; 39 : 359 – 367.
Neoplastic
Adenomas (4%) 5 – 20 mm, solitary
Miscellaneous Leiomyomas, lipomas,
neurofibromas, carcinoids
Non-neoplastic
Cholesterol polyp (60%) < 10 mm
Adenomyomatosis (25%) Usually fundus
Inflammatory (10%) < 10 mm
Risk of malignancy in GB polyps
• Size Small polyp not necessarily benign
Sessile polyps ≤ 10 mm quite aggressive
≥ 10 mm suspicious
> 18 mm usually invasive malignancy
• Patient age > 50
• Concurrent gall stones
• Diagnosis of PSC
Talley NJ et al. Practical gastroenterology & hepatology: Liver & biliary disease.
Wiley Blackwell, Oxford, UK, First edition, 2010.
Cholesterol polyp & cholesterolosis
Lamina propria infiltrated with lipid-laden foamy macrophages
Cholesterol polyp
Cholesterolosis
“ strawberry gallbladder”
Cholesterol polyp & cholesterolosis
Cholesterol polyp
Cholesterolosis
“ strawberry gallbladder”
Johnson CD et al. Mayo Clinic gastrointestinal imaging review.
Mayo Clinic Scientific Press, Rochester, USA, 2005.
Gallbladder polyps
Gallahan WC et al. Gastroenterol Clin N Am 2010 ; 39 : 359 – 367.
Sessile polypPedunculated polyp
Gallbladder polyp
Any size
PSC
Cholelithiasis
Sessile
Lap surgery
Talley NJ et al. Practical gastroenterology & hepatology: Liver & biliary disease.
Wiley Blackwell, Oxford, UK, First edition, 2010.
> 18 mm
Staging &
Open surgery
< 10 mm
Symptoms
Yes
Imaging: US or EUS
Every 6 months
Non
10 – 18 mm
No consensus guidelines to guide treatment
Management should be individualized
Variable Score
Tumor maximum size (mm) Value in mm
EUS in gallbladder polyp
Retrospective study of 70 surgical cases - Multivariate analysis
Sadamoto Y et al. Endoscopy 2002 ; 34 : 959 – 965.
Scores ≥ 12: neoplastic polyp
Sen: 78% – Sp: 83% – Accuracy: 83 %
Internal echo pattern
Heterogeneous
Homogeneous
4
0
Hyperechoic spotting
Single 1 – 5 mm hyperechoic spot
Multiple hyperechoic 1 – 3 mm spots
Presence: – 5
Absence: 0
EUS in gallbladder polyp
11 mm in diameter (11)
Homogenous (0)
Hyperechoic spots (– 5)
Cholesterol polyp GB adenoma
9 mm in diameter (9)
Heterogeneous (4)
Hyperechoic spots (0)
Sadamoto Y et al. Endoscopy 2002 ; 34 : 959 – 965.
Score: 6 Score: 13
Adenomyomatosis (Rokitansky-Aschoff sinuses)
8% of patients undergoing cholecystectomy
Fundic
Most frequent
Adenomyoma
Segmental
Hourglass
Diffuse
Excessive proliferation of surface epithelium
which can invaginate into muscularis
Diffuse adenomyomatosis of gallbladder
Thickened GB wall
Comet-tail artifacts in GB wall
„„Comet-tail” or „„ring-down‟‟ artifact
Diffuse adenomyomatosis of gallbladder
Thick gallbladder wall
Echogenic intramural foci
„„ring-down‟‟ artifacts
Multiple high signal intensity
structures within GB wall
“string of pearls” appearance
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
Segmental adenomyomatosis
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.
Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
Masslike areas obliterating lumen
Cystic spaces suggest diagnosis
Multiple echogenic foci
Crystals in sinuses suggest dg
Fundal adenomyomatosis
Hypoechoic mass-like
Fundal adenomyoma
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Thickened GB wall with small
Rokitansky-Aschoff sinus at fundus
 Gallbladder carcinoma
US of gallbladder carcinoma
3 major patterns of presentation
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
• Polypoid GB mass
25% of carcinoma – > 1 cm – Broad based – Role of EUS
• Mural thickening
Least common – Focal or diffuse – Irregular
Most difficult to diagnose
• Gallbladder fossa mass
Most common – Replacing GB – Invading adjacent liver
Gallbladder carcinoma – Mural thickening
Marked mural thickening of the neck of gallbladder
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
Gallbladder carcinoma – Polypoid mass
Enhancing mass in GB fundus
Rubens DJ et al. Ultrasound Clin 2007 ; 2 : 391 – 413.
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
2-cm polypoid mass in GB fundus
Internal vascularity
Villous adenoma with foci of CIS
Gallbladder carcinoma – Gallbladder fossa mass
Mass occupying GB fossa
Coronal reformatted CT scan
Rubens DJ et al. Ultrasound Clin 2007 ; 2 : 391 – 413.
Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
Immobile gallstones
Heterogeneous mass in GB fossa
Some vascularity on color Doppler
Color Doppler US
Malignant tumors of gallbladder
• Most frequent Adenocarcinoma
• Unusual histologic variants Papillary adenocarcinoma
Mucinous adenocarcinoma
Signet ring cell–type
• Unusual malignancies Squamous cell carcinoma
Carcinosarcoma
Small cell carcinoma
Lymphoma
Metastasis
Kim MJ et al. AJR 2006 ; 187 : 473 – 480.
Radiologic findings overlap with ordinary GB carcinoma
Signet ring cell carcinoma of gallbladder
Kim MJ et al. AJR 2006 ; 187 : 473 – 480.
Target-like wall thickening of
gallbladder
Targetlike wall thickening of GB
Enhancement of gallbladder fundus
Massive necrotic LN along porta
hepatis & hepatoduodenal ligament
 Miscellaneous: volvulus – nonvisualization
Volvulus of gallbladder
Mobile GB with long suspensory mesentery
• Rare acute entity
• Symptoms of acute cholecystitis
• Often seen in elderly females
• US findings:
Massively distended & inflamed GB
Unusual location of gallbladder
Unusual horizontal long axis in left to right direction
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.
Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
Volvulus of gallbladder
Nonvisualization of gallbladder
• Previous cholecystectomy
• Chronic cholecystitis
• Contracted GB: postprandial – cystic fibrosis
• Porcelain gallbladder with shadowing
• Air-filled GB or emphysematous cholecystitis
• Agenesis of gallbladder
• Ectopic location
• Tumefactive sludge
• GB carcinoma completely filling gallbladder
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic ultrasound.
Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
Micro-gallbladder in cystic fibrosis
Bates J A. Abdominal Ultrasound: How, Why and When.
Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
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Ultrasound of the gallbladder

  • 1. Ultrasound of the gallbladder Samir Haffar M.D. Assistant Professor of Gastroenterology
  • 2. Ultrasound of the gallbladder  Normal GB ultrasound  Congenital abnormalities  GB stones & sludge  Acute cholecystitis & its complications  Chronic cholecystitis  Polyps & adenomyomatosis  GB carcinoma  Miscellaneous: volvulus – nonvisualization
  • 3.  Normal GB ultrasound
  • 4. Anatomy of the gallbladder Sherlock S & Dooley J. Diseases of the liver and biliary system. Blackwell Science, Oxford, UK, 11th edition, 2002.
  • 5. Normal ultrasound of gallbladder Minimum 6 hours of fasting Subcostal or intercostal scanning Supine – LLD – Prone – Erect GB wall ≤ 3 mm Anterior wall Long-axis Perpendicular Transverse diameter < 4 cm Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005. F B N
  • 6. Gallbladder folds Abraham D et al. Emergency medicine sonography: Pocket guide. Jones & Bartlett Publishers, Boston, MA, USA, 1st edition, 2010. Longitudinal view of gallbladder Hartman’s pouch Phrygian cap
  • 7. Gallbladder folds Phrygian cap (fundus over body) Fold between neck & body Sigmoid GB (multiple folds)
  • 8. Acoustic shadow from a GB fold Part of a fold within gallbladder producing an acoustic shadow When only part of fold is visualized, it may mimic a polyp or a stone McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  • 9. Edge refraction shadow McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Shadow near neck of GB on longitudinal section Absence of visible stone at origin of shadow Scanning in different positions
  • 10. Proximal cystic duct Longitudinal view of GB neck & proximal cystic duct Serrated appearance of cystic duct secondary to valves of Heister Occasionally identified on sonography McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  • 11. Distal cystic duct Normal distal cystic duct entering the CBD posteriorly Parulekar SG. Ultrasound Quarterly 2002 ; 18 : 187 – 202.
  • 13. Congenital abnormalities of the gallbladder • Agenesis of gallbladder Confirmation with other tests • Anomalous GB location Abnormal locations • Duplication of gallbladder One or two cystic ducts • Septated gallbladder Honeycomb appearance • Gallbladder diverticulum Any location in gallbladder McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  • 14. Congenital anomalies of the gallbladder Yamada T et all. Textbook of gastroenterology. Wiley-Blackwell, Oxford, UK, 5th edition, 2009. Septated GBDuplicated GB Diverticulum
  • 15. Agenesis of gallbladder 1 in 6,000 live births – fewer than 300 reported cases Waller AH et al. Clin Gastroenterol Hepatol 2008 ; 6 : 38. • First described by Lemery in 1701 • Failure of cystic bud to develop in fourth week of life • Associated with chromosomal abnormalities • Symptoms attributed to biliary dyskinesia • US diagnosis: absence of gallbladder • HIDA scan: acute cholecystitis Diagnosis usually obtained after surgical exploration
  • 16. Agenesis of gallbladder Waller AH et al. Clin Gastroenterol Hepatol 2008 ; 6 : 38. HIDA scan Uptake by liver Excretion into CBD & bowel No visualization of gallbladder MRI & MRCP No visualization of normal or ectopic GB Normal biliary tree
  • 17. Anomalous location of gallbladder Rare – Reported only in isolated case reports Most common locations • Left side (posterior to left lobe) • Intrahepatic • Suprahepatic (right lobe & diaphragm) • Retrohepatic (posterior to right lobe) Intrahepatic GB May preclude Lap surgery McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  • 18. Duplication of gallbladder One in 3000 to 4000 GB 2 gallbladders adjacent to each other with 2 separate cystic ducts After meals, both gallbladders showed normal emptying www.ultrasound-images.com/gall-bladder.htm
  • 19. Multi-septate gallbladder Congenital origin – Very rare • Entire GB or part of lumen • Chambers communicate by orifices • Isolated or coexist with other anomalies • Symptoms of recurrent cholecystitis • Multiple linear fine echogenic septations Oriented horizontally or vertically Kapoor V et al. J Ultrasound Med 2002 ; 21 : 677 – 680.
  • 20. True diverticulum of gallbladder Extreme rarity Occurs anywhere in GB Usually single Varies greatly in size McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  • 22. US of gallbladder stone Gold standard for diagnosis of cholelithasis 3 sonographic criteria • Echogenic focus • Cast acoustic shadow • Seek gravitational dependence Stones < 2 – 3 mm may be difficult to visualize Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
  • 23. Shadow of gallbladder stone * Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287. ** Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413. 3 patterns of shadowing*  Clean shadow Solitary stone  Confluent shadowing Multiple small stones  Wall-Echo-Shadow (WES) GB filled with gallstones ** Soft pigment stones may not shadow
  • 24. Confluent shadowing of GB stones Multiple small stones gravel abut each other with confluent AS Mural thickening of gallbladder
  • 25. Acoustic shadow of a gallbladder stone Time gain compensation too high Time gain compensation is lower Bates J A. Abdominal Ultrasound: How, why and when. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
  • 26. Stone smaller than the beam Shadowing of the stones Shadow Bates J A. Abdominal Ultrasound: How, why and when. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004 Stone occupies width of the beam Large stone outside focal zone Large stone just out of beam No shadow
  • 27. Floating stones Bates J A. Abdominal Ultrasound: How, Why and When. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004 Floating stones just below anterior gallbladder wall
  • 28. Tissue harmonic imaging & gallstones Longitudinal ultrasound Normal gallbladder Rubens D. Radiol Clin North Am 2004 ; 42 : 257 – 78. Harmonic imaging Multiple small stones
  • 29. Correct & incorrect positions for prone scanning Demonstrates gravitational dependence of stone Correct: transducer as vertically as possible to image anterior GB wall Incorrect: most dependent anterior part of GB not well examined Hough DM et al. J Ultrasound Med 2000 ; 19 : 633 – 638.
  • 30. Pitfalls in diagnosis of GB stone Residue in bowel indenting posterior wall of GB mimics gallstones McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  • 31. Dependent debris in the gallbladder • Sludge • Pseudosludge • Blood • Pus • Milk of calcium bile McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  • 32. Biliary sludge Prevalence unknown in general population • Predisposing factors Pregnancy Rapid weight loss & prolonged fasting Long-term TPN Ceftriaxone – Prolonged octreotide tt Bone marrow transplantation • Evolution (3 years) 50% resolve spontaneously 20% persist asymptomatically 5 – 15 % develop gallstones 10 – 15 % become symptomatic • Complications Biliary colic, AAC, pancreatitis
  • 33. Biliary sludge Also known as biliary sand Low-amplitude nonshadowing echoes in dependent portion of GB Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287. Occasionally, sludge can be highly echogenic
  • 34. Pseudosludge McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Most commonly along posterior surface of gallbladder Produced by “sidelobe artifacts” Disappear in different positions & when central portion of GB scanned
  • 35. Aggregated sludge – Sludge ball McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Change in appearance or disappearance on follow-up Differentiates sludge ball from a stone or neoplasm Nonshadowing mobile echogenic structures
  • 36. Aggregated sludge – Tumefactive sludge GB with tumor-like sludge Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005. Potential mobility of sludge Normal gallbladder wall No vascularity detected on Doppler US Follow-up
  • 37. Biliary sludge "hepatization" of gallbladder Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005. GB entirely filled with sludge isoechoic to adjacent liver Recognized by identifying normal GB wall
  • 38. Blood in the gallbladder Clinical history very useful for diagnosis Sonographic findings • Echogenic or mixed echogenicity • Fluid with low-level internal echoes • Retractile • May be mobile Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005. Angled edges of clot Quite typical of blood clots
  • 39. Milk of calcium bile (limey bile) Diagnosis can be confirmed by abdominal radiography or CT High-attenuation material within dependent portion of GB Highly echogenic material in dependent portion of GB with AS Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
  • 40. Milk of calcium bile (limey bile) Abdominal radiography
  • 41.  Acute cholecystitis & its complications
  • 42. Causes of right upper quadrant pain • Peptic ulcer disease • Pancreatitis • Hepatitis • Appendicitis • Hepatic congestion from right-sided heart failure • Perihepatitis (Fitz-Hugh-Curtis syndrome) • Right lower lobe pneumonia • Right-sided pyelonephritis • Nephro-ureterolithiasis
  • 43. Diagnostic standard for acute cholecystitis Tokyo guidelines 2007 Hirota M et al. J Hepatobiliary Pancreat Surg 2007 ; 14 : 78 – 82 . Three categories of diagnostic findings One criterion from each category must be fulfilled (1) Murphy sign or pain/tenderness in RUQ or RUQ mass (2) Fever, leukocytosis, or elevated CRP (3) Confirmation by US or HIDA scan
  • 44. Acute cholecystitis – HIDA scan Higher accuracy than ultrasonography Talley NJ et al. Practical gastroenterology & hepatology: Liver & biliary disease. Wiley Blackwell, Oxford, UK, First edition, 2010. Tracer in GB Tracer in CBD Tracer in small bowel GB CBD Small bowel Normal HIDA scan Non-filling of GB Tracer in CBD Tracer in small bowel CBD Small bowel Acute cholecystitis
  • 45. Sonographic findings in acute cholecystitis • Impacted stone in cystic duct or GB neck • Positive sonographic Murphy's sign • Thickening of GB wall (>3 mm) • Distention of GB lumen (> 4 cm) • Pericholecystic fluid collections (frequent) • Hyperemic GB wall on color Doppler (supportive test) None of above signs pathognomonic Combination of multiple signs make correct diagnosis Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
  • 46. Acute cholecystitis Caused by gallstones in more than 90% of cases Large obstructing stone within GB neck Thick hypoechoic gallbladder wall Positive sonographic Murphy sign Ralls PW et al. Gastroenterol Clin N Am 2002 ; 31 : 801–825.
  • 47. Negative sonographic Murphy’s sign • Patients who received pain medicine or steroids • Para or quadriplegic patients • Patients not able to give reliable history or pain response • Denervated GB: DM – gangrenous cholecystitis • Gallbladder rupture Careful attention to clinical status important when assessing for sonographic Murphy‟s sign Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.
  • 48. Gallbladder wall thickening • Generalized edematous states CHF – Renal failure End-stage cirrhosis Hypoalbuminemia • Inflammatory conditions Primary Acute cholecystitis Chronic cholecystitis Cholangitis Secondary Acute hepatitis Perforated DU Pancreatitis Diverticulitis/colitis • Neoplastic conditions Adenocarcinoma – Metastases • Miscellaneous Adenomyomatosis – Varices Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
  • 49. Diffuse gallbladder wall thickening McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Three echo patterns (not specific)  Uniformly echogenic pattern  Central hypoechoic zone & 2 peripheral echogenic layers  Striated pattern
  • 50. Gallbladder wall thickening Uniformly echogenic pattern Echogenic thickening of the wall in chronic cholecystitis McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  • 51. Gallbladder wall thickening Central hypoechoic zone separated by two echogenic layers Gallbladder wall thickening due to ascites
  • 52. Gallbladder wall thickening Striated pattern Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413. Striated wall with alternating echogenic & hypoechoic layers Striated wall in setting of acute cholecystitis: gangrenous cholecystitis Striated wall without evidence of acute cholecystitis: non specific
  • 53. Gallbladder wall thickening Rubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 – 413. Gallstones Focal GB wall thickening (7 mm) Free air with reverberation shadows Pericholecystic fluid (arrows) Free air (arrowheads) Extraluminal air (paired arrowheads) Peptic ulcer perforation
  • 54. Gallbladder wall thickening Rubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 – 413. Focal pyelonephritis Heterogeneous decreased attenuation area typical of focal pyelonephritis GB wall thickening 3-cm echogenic mass in lower pole of rt kidney
  • 55. Pericholecystic fluid Two specific patterns Type I Thin anechoic crescent-shaped collection adjacent to gallbladder wall Nonspecific finding Type II Round or irregularly shaped collection with thick walls, septations, or internal debris Associated with GB perforation & abscess Teefey SA et al. J Ultrasound Med 1991 ; 10 : 603 – 6. Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.
  • 56. Acute cholecystitis Hyperemic GB wall McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Color Doppler sonography Increased vascularity in GB wall Supportive test
  • 57. Acute acalculous cholecystitis (AAC) 5 – 15% of acute cholecystitis • Critically ill patients Major surgery Severe trauma Sepsis Total parenteral nutrition Diabetes Atherosclerotic disease HIV infection • Nonhospitalized patients Elderly male with atherosclerosis HIDA scan & sampling of luminal contents help to establish the diagnosis
  • 58. Acute acalculous cholecystitis (AAC) Difficult to diagnose clinically & on imaging Marked GB mural thickening Hypoechoic regions within wall Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287. Marked GB mural thickening with hypo & hyperenhancing areas
  • 59. Complications of acute cholecystitis • Suppurative cholecystitis (empyema) • Gangrenous cholecystitis Up to 20% • Emphysematous cholecystitis 1 % • Hemorrhagic cholecystitis Rare • Gallbladder perforation 5 – 10%
  • 60. Suppurative cholecystitis (Empyema) Patients very ill with fever & acute pain Fine echoes caused by pus in bile Pericholecystic GB collection (leakage) US used to guide drainage before surgery Bates J A. Abdominal Ultrasound: How, why and when. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004 Large GB full of pus & stones
  • 61. Gangrenous cholecystitis No specific diagnostic US findings • Striated thickening of GB wall • Intraluminal membranes (5%) • Marked asymmetry of GB wall • Echogenic debris within GB • Pericholecystic fluid collections • US Murphy’s sign negative in 70% Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287. Mucosal sloughing Echogenic debris within GB
  • 62. Gangrenous cholecystitis Mucosal sloughing Rubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413. Longitudinal US of gallbladder Intraluminal membranes associated gallbladder gangrene Stone impacted in gallbladder neck
  • 63. Emphysematous cholecystitis Prompt surgical intervention required • Organisms Clostridium welchii & Escherichia coli • Characteristics Male preponderance (70%) Frequent occurrence in diabetic (50%) Lack of gallstones in up to one third Higher risk of gangrene & perforation • Three stages Stage 1: Gas in GB lumen Stage 2: Gas in GB wall Stage 3: Gas in pericholecystic tissues Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216. Appearance depends on amount of gas present
  • 64. Emphysematous cholecystitis Associated with DM & atherosclerotic disease Intraluminal & intramural gas bubbles Debris within necrotic GB Higher sensitivity of CT for the diagnosis Diagnosis should be confirmed by abdominal radiography or CT Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
  • 65. Emphysematous cholecystitis Small amount of gas Supine position Presence of echoes anteriorly Could be in the lumen or the wall Rubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413. Upright position Gas moves & breaks into bubbles Distinguishing it from calcium
  • 66. Emphysematous cholecystitis Large amount of gas Absence of a normal gallbladder is a clue Gas in GB completely obscures the lumen (dirty shadow) Bates J A. Abdominal Ultrasound: How, Why and When. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004 Location of GB fossa essential to avoid mistaking this for bowel gas
  • 67. Emphysematous cholecystitis Abdominal radiography Intraluminal & intramural gas bubbles Bates J A. Abdominal Ultrasound: How, Why and When. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
  • 68. Gallbladder perforation 5 – 10 % of patients with acute cholecystitis Small defect in GB wall: not always seen Deflation of the gallbladder Pericholecystic fluid collection Pericholecystic abscess Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005. Disruption of GB wall
  • 69. GB perforation – Pericholecystic abscess Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005. Abscess (internal strands typical of abscess) Echogenic inflamed fat Small amount of ascites
  • 70. Hemorrhagic cholecystitis Rare – Atherosclerosis – High mortality rate Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216. Echogenic material with higher echogenicity than sludge Increased density of bile
  • 71. Hemorrhagic cholecystitis Differential diagnosis • Blood in gallbladder Neoplasm Aneurysms Trauma Anticoagulation Ectopic pancreas Ectopic gastric mucosa • High-density bile Recently administered IV contrast Milk of calcium bile Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216.
  • 73. Forms of chronic cholecystitis • Traditional chronic cholecystitis Thick gallbladder wall with gallstones • Wall-Echo-Shadow complex (WES) Double arc-shadow sign • Porcelain gallbladder High incidence of GB carcinoma (10 – 30%) • Xanthogranulomatous cholecystitis (XGC) Difficult to distinguish from adenomyomatosis & gallbladder carcinoma
  • 74. Chronic cholecystitis Bates J A. Abdominal Ultrasound: How, Why and When. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004 Thick gallbladder wall Small gallbladder stone with posterior AS Bouts of acute cholecystitis may complicate chronic cholecystitis
  • 75. Wall-Echo-Shadow complex (WES) Contracted gallbladder filled with stones 2 parallel arcuate hyperechoic lines Separated by thin hypoechoic space Distal acoustic shadowing McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Differentiation from air or calcification in GB wall Normal GB wall not seen; only bright echo & AS seen
  • 76. Porcelain gallbladder Calcified wall with acoustic shadow Mistaken for stone within GB lumen No GB wall visible Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005. Dense calcification in GB fundus
  • 77. Porcelain gallbladder – Mild calcification Rickes S et al. N Engl J Med, 2002 ; 346 : e4. Computed tomography Gallstones Calcification of GB wall Ultrasonography Gallstones (one in cystic duct) leading to GB enlargement (5 cm) Calcification of GB wall
  • 79. Xanthogranulomatous cholecystitis (XGC) 2% of cholecystectomy specimens Compressed lumen Multiple large mural nodules separated by enhancing margins Stone not visualized Compressed lumen Multiple hypoechoic mural nodules Wall markedly thickened Adjacent stone Rubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413.
  • 80.  GB polyps & adenomyomatosis
  • 81. Classification of gallbladder polyps 3 – 7% of subjects undergoing US Gallahan WC et al. Gastroenterol Clin N Am 2010 ; 39 : 359 – 367. Neoplastic Adenomas (4%) 5 – 20 mm, solitary Miscellaneous Leiomyomas, lipomas, neurofibromas, carcinoids Non-neoplastic Cholesterol polyp (60%) < 10 mm Adenomyomatosis (25%) Usually fundus Inflammatory (10%) < 10 mm
  • 82. Risk of malignancy in GB polyps • Size Small polyp not necessarily benign Sessile polyps ≤ 10 mm quite aggressive ≥ 10 mm suspicious > 18 mm usually invasive malignancy • Patient age > 50 • Concurrent gall stones • Diagnosis of PSC Talley NJ et al. Practical gastroenterology & hepatology: Liver & biliary disease. Wiley Blackwell, Oxford, UK, First edition, 2010.
  • 83. Cholesterol polyp & cholesterolosis Lamina propria infiltrated with lipid-laden foamy macrophages Cholesterol polyp Cholesterolosis “ strawberry gallbladder”
  • 84. Cholesterol polyp & cholesterolosis Cholesterol polyp Cholesterolosis “ strawberry gallbladder” Johnson CD et al. Mayo Clinic gastrointestinal imaging review. Mayo Clinic Scientific Press, Rochester, USA, 2005.
  • 85. Gallbladder polyps Gallahan WC et al. Gastroenterol Clin N Am 2010 ; 39 : 359 – 367. Sessile polypPedunculated polyp
  • 86. Gallbladder polyp Any size PSC Cholelithiasis Sessile Lap surgery Talley NJ et al. Practical gastroenterology & hepatology: Liver & biliary disease. Wiley Blackwell, Oxford, UK, First edition, 2010. > 18 mm Staging & Open surgery < 10 mm Symptoms Yes Imaging: US or EUS Every 6 months Non 10 – 18 mm No consensus guidelines to guide treatment Management should be individualized
  • 87. Variable Score Tumor maximum size (mm) Value in mm EUS in gallbladder polyp Retrospective study of 70 surgical cases - Multivariate analysis Sadamoto Y et al. Endoscopy 2002 ; 34 : 959 – 965. Scores ≥ 12: neoplastic polyp Sen: 78% – Sp: 83% – Accuracy: 83 % Internal echo pattern Heterogeneous Homogeneous 4 0 Hyperechoic spotting Single 1 – 5 mm hyperechoic spot Multiple hyperechoic 1 – 3 mm spots Presence: – 5 Absence: 0
  • 88. EUS in gallbladder polyp 11 mm in diameter (11) Homogenous (0) Hyperechoic spots (– 5) Cholesterol polyp GB adenoma 9 mm in diameter (9) Heterogeneous (4) Hyperechoic spots (0) Sadamoto Y et al. Endoscopy 2002 ; 34 : 959 – 965. Score: 6 Score: 13
  • 89. Adenomyomatosis (Rokitansky-Aschoff sinuses) 8% of patients undergoing cholecystectomy Fundic Most frequent Adenomyoma Segmental Hourglass Diffuse Excessive proliferation of surface epithelium which can invaginate into muscularis
  • 90. Diffuse adenomyomatosis of gallbladder Thickened GB wall Comet-tail artifacts in GB wall „„Comet-tail” or „„ring-down‟‟ artifact
  • 91. Diffuse adenomyomatosis of gallbladder Thick gallbladder wall Echogenic intramural foci „„ring-down‟‟ artifacts Multiple high signal intensity structures within GB wall “string of pearls” appearance Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
  • 92. Segmental adenomyomatosis Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005. Masslike areas obliterating lumen Cystic spaces suggest diagnosis Multiple echogenic foci Crystals in sinuses suggest dg
  • 93. Fundal adenomyomatosis Hypoechoic mass-like Fundal adenomyoma Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005. Thickened GB wall with small Rokitansky-Aschoff sinus at fundus
  • 95. US of gallbladder carcinoma 3 major patterns of presentation Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287. • Polypoid GB mass 25% of carcinoma – > 1 cm – Broad based – Role of EUS • Mural thickening Least common – Focal or diffuse – Irregular Most difficult to diagnose • Gallbladder fossa mass Most common – Replacing GB – Invading adjacent liver
  • 96. Gallbladder carcinoma – Mural thickening Marked mural thickening of the neck of gallbladder Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
  • 97. Gallbladder carcinoma – Polypoid mass Enhancing mass in GB fundus Rubens DJ et al. Ultrasound Clin 2007 ; 2 : 391 – 413. Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287. 2-cm polypoid mass in GB fundus Internal vascularity Villous adenoma with foci of CIS
  • 98. Gallbladder carcinoma – Gallbladder fossa mass Mass occupying GB fossa Coronal reformatted CT scan Rubens DJ et al. Ultrasound Clin 2007 ; 2 : 391 – 413. Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287. Immobile gallstones Heterogeneous mass in GB fossa Some vascularity on color Doppler Color Doppler US
  • 99. Malignant tumors of gallbladder • Most frequent Adenocarcinoma • Unusual histologic variants Papillary adenocarcinoma Mucinous adenocarcinoma Signet ring cell–type • Unusual malignancies Squamous cell carcinoma Carcinosarcoma Small cell carcinoma Lymphoma Metastasis Kim MJ et al. AJR 2006 ; 187 : 473 – 480. Radiologic findings overlap with ordinary GB carcinoma
  • 100. Signet ring cell carcinoma of gallbladder Kim MJ et al. AJR 2006 ; 187 : 473 – 480. Target-like wall thickening of gallbladder Targetlike wall thickening of GB Enhancement of gallbladder fundus Massive necrotic LN along porta hepatis & hepatoduodenal ligament
  • 101.  Miscellaneous: volvulus – nonvisualization
  • 102. Volvulus of gallbladder Mobile GB with long suspensory mesentery • Rare acute entity • Symptoms of acute cholecystitis • Often seen in elderly females • US findings: Massively distended & inflamed GB Unusual location of gallbladder Unusual horizontal long axis in left to right direction Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
  • 104. Nonvisualization of gallbladder • Previous cholecystectomy • Chronic cholecystitis • Contracted GB: postprandial – cystic fibrosis • Porcelain gallbladder with shadowing • Air-filled GB or emphysematous cholecystitis • Agenesis of gallbladder • Ectopic location • Tumefactive sludge • GB carcinoma completely filling gallbladder Rumack CM, Wilson SR, & Charboneau JW. Diagnostic ultrasound. Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
  • 105. Micro-gallbladder in cystic fibrosis Bates J A. Abdominal Ultrasound: How, Why and When. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004

Notas del editor

  1. The gallbladder is a pear-shaped bag 9 cm long with a capacity of about 50 ml.The gallbladder is divided into the fundus, body, and neck, with the fundus being the most anterior, and often inferior, segment.In the region of the neck, there may be an infundibulum, called Hartmann&apos;s Pouch, which is a common location for impaction ofgallstones.Within the cystic duct and sometimes the gallbladder neck, small mucosal folds exist called the spiral valves of Heister; these are occasionally identified on sonography.
  2. Normal gallbladder showing a thin fold.Normal gallbladder capacity: 30 to 50 mL
  3. Phrygian : الفريجي أحد أبناء فريجيا القديمة بآسيا الوسطىcap : قلنسوة غطاء الرأس
  4. Serrated: مسنن – مشرشر - منشاريValves of Heister areoccasionally identified on sonography.
  5. Agenesis of gallbladder: 1 in 6,000 live births
  6. 72-year-old Hispanic woman had an 8-day history of right upper quadrant pain radiating to the right scapula.Ultrasonography revealed cholelithiasis, gallbladder wall thickening, and a dilated common bile duct.The patient had a laparoscopic cholecystectomy, which was promptly converted to open technique due to failure to identify gallbladder. Exploratory laparotomy was done with complete dissection and skeletonization of vascular and biliary structures, as well as pancreaticoduodenal areas. These maneuvers were unsuccessful in revealing a gallbladder. The common bile duct was identified and found to be dilated (20 mm). It was explored, and an intraoperativecholangiogram through a T-tube did not show cystic duct, gallbladder, or stones. A T-tube was placed at the time of surgery, and bilirubin subsequently returned to a normal level. The T-tube was removed 4 weeks later without sequelae.
  7. hepatobiliaryiminodiacetic acid (HIDA) scan
  8. Failure to migrate may lead to an intrahepatic, or partially intrahepatic, gallbladder, a rare but significant finding that may preclude laparoscopic surgery.Other reported ectopic sites include the gallbladder in the retroperitoneum posterior to the right kidney, lateral to the right lobeof the liver, within the falciform ligament, within the anterior abdominal wall, and in the lesser peritoneal sac.
  9. Two cystic structures with septum of entire length of 2 cavitiesTwo cystic structures separated from each otherTriple &amp; quadruple GB have also been reportedDefinitive diagnosis of double gallbladder requires demonstration, which is difficult sonographically, of two separate cystic ducts.
  10. Harmonic imaging significantly improves visualization of small gallstonesThis type of ultrasound transmits the insonating US beam at a fundamental frequency, such as 2.5 or 3 MHz, and receives the returningechoes not only at the fundamental frequency but also at the second harmonic frequency that is twice the fundamental frequency creatingthe image with the higher harmonic frequency. By eliminating the fundamental frequency, this technique significantly reduces degradation of the image by noise, since lower frequencies easily can be filtered out. In addition, scattering of the US beam from fat in the anterior abdominal wall is diminished because the harmonic frequencies are generated after the beam enters the body. The narrower harmonic beam also has fewer side lobes, and therefore, improved lateral resolution and signal to noise ratio. Harmonic imaging increases the echogenicity of gallstones and strengthens their posterior shadows, permitting visualization of stones not seen with conventional grayscale ultrasound.
  11. Gallbladder sludge is thick viscous bile that consists of cholesterol monohydrate crystals and calcium bilirubinate granules embedded in a gel matrix of mucus glycoproteins.It often develops in patients with prolonged fasting in intensive care units, trauma patients receiving total parenteral nutrition, and within 5 to 7 days of fasting in patients who have undergone gastrointestinal surgery. Sludge typically has a fluctuating course and may disappear and reappear over several months or years. Sludge may be an intermediate step in the formation of gallstones. Some 5 - 15% of patients with sludge will develop asymptomatic gallstones.
  12. Aggregate: يتجمع - يتكتلBall: كرة
  13. Tumefactive: محدث ورماTumefactive sludge (arrowheads) appears as a polypoid mass within the gallbladder.
  14. Milk of calcium bile or limey bile is an uncommon disorder characterized by puttylike, thickened bile composed of calcium carbonate. It is usually associated with cystic duct obstruction and chronic cholecystitis.Sonographically, milk of calcium bile demonstrates echogenic layering material with a flat or convex meniscus usually associated with acoustic shadowing. Occasionally a weak reverberation artifact may be produced. CT and plain radiographs show high-attenuation material layering within the gallbladder lumen.Diagnosis can be confirmed by abdominal radiography or CT.
  15. HIDA (Hepatic Imino-Diacetic Acid) imagesRadionuclide cholescintigraphy with technetium Tc 99m-labelled iminodiacetic acid analogs (hepatobiliaryiminodiacetic acid scan) was first introduced in the late 1970s. The hepatic parenchymal uptake is observed within 1 minute, with peak activity occurring at 10 to 15 minutes. The bile ducts are usually visualized within 10 minute. The gallbladder should fill with isotope within 1 hour if the cystic duct is patent. If the gallbladder is not identified, delayed imaging up to 4 hours should be performed.Prompt biliary excretion of the isotope without visualization of the gallbladder is the hallmark of acute cholecystitis.False-positive results may occur in patients with abnormal bile flow because of hepatic parenchymal disease or a prolonged fast with a distended, sludge-filled gallbladder.Delayed gallbladder filling can be seen in the setting of chronic cholecystitis.
  16. Positive sonographic Murphy’s sign and the presence of gallstones had a positive predictive value of 92% for the diagnosis of acute cholecystitis.Patients who have thickening of the gallbladder wall caused by etiologies other than acute cholecystitis, the gallbladder often is nondistended, implying a nonobstructive (non-biliary) cause of wall thickening.
  17. The sonographic Murphy’s sign is defined as the presence of maximal tenderness elicited by direct pressure of the transducer over a sonographically localized gallbladder. The sonographic Murphy’s sign is different from surgical Murphy’s sign, which consists of arrest of inspiration caused by pain from an inflamed gallbladder when the examiner’s hand is placed on the patient’s subcostal right upper quadrant.
  18. Striated:مخطط – مقلم - محزز
  19. Identifying the presence of pericholecystic fluid is useful because it is highly specific for GB disease either:1- Acute cholecystitis2- Pericholecystic abscess3- GB perforation
  20. AAC typically results from a gradual increase of bile viscosity because of prolonged stasis that leads to functional obstruction of cystic duct.The diagnosis of acalculouscholecystitis can be difficult to make as gallbladder distention, wall thickening, internal sludge, &amp; pericholecystic fluid may all be present in critically ill patients without cholecystitis.Because no stones are present, the diagnosis is more difficult and may be delayed.The patients may be obtunded or receiving analgesics, reducing the sensitivity of Murphy&apos;s sign. It is the combination of the findings that suggests the diagnosis; the more signs present, the more the likelihood of cholecystitis. Nevertheless, cholescintigraphy or percutaneous sampling of the luminal contents should be used more liberally to aid in establishing the diagnosis.
  21. Sonographic findings of AAC include:Gallbladder distention and sludgeMural thickening (other etiologies considered unlikely)Hypoechoic regions within the wallPericholecystic fluidDiffuse increased echogenicity within the gallbladder resulting from hemorrhage, pus, intraluminal membranesPositive sonographic Murphy’s sign (50%)
  22. Emphysematous : نفاخي
  23. Gangrenous cholecystitis is a major complication of acute cholecystitis and is associated with significantly increased morbidity and mortality, requiring emergency cholecystectomy. The pathologic features include hemorrhage, necrosis, and microabscesses within the wall of the gallbladder, mucosal ulcers as well as strands of fibrinousexudate, and purulent debris within the gallbladder. The incidence of gangrenous cholecystitis has been reported to be between 2% and 38% of all patients with acute cholecystitis. Perforation of the gallbladder can occur in up to 10% of cases of acute cholecystitis, frequently a sequela of gangrenous cholecystitis. Clinical findings are variable, and it is difficult to diagnose gangrenous cholecystitis clinically. The disorder has no specific diagnostic sonographic findings. However, in the clinical setting of acute cholecystitis, several sonographic features suggest gangrenous cholecystitis, including striated thickening of the wall, intraluminal membranes, marked asymmetry of the gallbladder wall causing focal irregularities or mass-like intraluminal protrusions from the wall, nonlayeringechogenic debris within the gallbladder, and loculatedpericholecystic fluid collections containing debris. Sonographic Murphy’s sign may be negative in up to 70% of patients with gangrenous cholecystitis, possibly because of denervation of the gallbladder wall by gangrenous changes.
  24. First described in 1931 by Hegner. Emphysematous cholecystitis is definitively treated with cholecystectomy, although percutaneouscholecystostomy may be used as an initial temporizing procedure in critically ill patients.The overall mortality rate for patients with the emphysematous form of cholecystitis is 15%, compared with a rate of less than 4% in uncomplicated cases of acute cholecystitis.
  25. Small amounts of gas appear as echogenic lines with posterior dirty shadowing or reverberation artifact (ringdown). Large amounts of gas can be more difficult to appreciate; the absence of a normal gallbladder is a clue.A bright echogenic line with posterior dirty shadowing is seen within the entire gallbladder fossa. Movement of gas bubbles is a helpful finding, and compression of the gallbladder fossa may precipitate this sign.
  26. Small amounts of gas appear as echogenic lines with posterior dirty shadowing or reverberation artifact (ringdown). Large amounts of gas can be more difficult to appreciate; the absence of a normal gallbladder is a clue.A bright echogenic line with posterior dirty shadowing is seen within the entire gallbladder fossa. Movement of gas bubbles is a helpful finding, and compression of the gallbladder fossa may precipitate this sign.
  27. Some 5% to 10% of patients with acute cholecystitis develop gallbladder perforation.It occurs most commonly in the setting of gangrenous cholecystitiswith other risk factors including gallstones, impaired vascular supply, infection, malignancy, and steroid use. The fundus of the gallbladder is the most common site of perforation because it has the most tenuous blood supply.The focus of perforation, seen as a small defect or rent in the wall of the gallbladder, is often, but not always, visible.Clues to perforation are the deflation of the gallbladder with loss of its normal gourdlike shape, and a pericholecystic fluid collection.The latter is often a small fluid collection about the wall defect, in distinction to the thin rim of fluid about the entire organ present in uncomplicated cholecystitis.The collection may have internal strands typical of abscesses elsewherePerforation of the gallbladder may extend into the adjacent liver parenchyma, forming an abscess collection. The presence of a cystic liver lesion about the gallbladder fossa should raise the possibility of a pericholecystic abscess.
  28. This rare complication of acute cholecystitis results from hemorrhage secondary to mucosal ulceration and necrosis and has been reported in the presence and absence of gallstones. Atherosclerosis of the gallbladder wall is a major predisposing factor.Classically the patient presents with biliary colic, jaundice, and melena.Only occasionally does the patient experience a gastrointestinal bleed.At sonography, blood in the gallbladder appears as echogenic material within the lumen which higher echogenicity than sludge. This may form a dependent layer; however, blood clots may appear as clumps or masses adherent to the gallbladder wall.As the hemorrhage evolves, this may have a cystic appearance.Prompt diagnosis is essential because hemorrhagic cholecystitis is associated with a high mortality rate.
  29. Wall-Echo-Shadow complex (WES) or Double arc-shadow signThe proximal hyperechoic arc represents the wall of the gallbladder. The distal hyperechoic arc represents the reflections from gallstonesThe hypoechoic space in between represents either a small sliver of bile between the wall of the gallbladder and the gallstones or a hypoechoic portion of the wall of the gallbladder.When air or calcification is present, the normal gallbladder wall is not seen; only the bright echo and the posterior shadowing are seen.
  30. Its cause is unknown, but occurs inassociation with gallstone disease and may represent a form of chronic cholecystitis.The term derives from the brittle consistency of the gallbladder.The entire wall or only part of the wall of the gallbladder may be calcified.Patients often have few symptoms, and the diagnosis is often made by detecting a palpable right upper quadrant mass or finding typical calcifications on plain radiographs. Prophylactic cholecystectomy is advocated in these patients, even in the paucity of symptoms, because of the strikingly high incidence (11%–33%) of carcinoma of the gallbladder.Differential diagnosis includes gallstones and emphysematous cholecystitis. Because the calcifications occur in the wall of the gallbladder, the WES complex is absent
  31. Rare form of chronic cholecystitis. Gallbladder wall is infiltrated by foamy histiocytes, lymphocytes, polymorphonuclear leukocytes, fibroblasts, and giant cells. The cause is probably similar to that of xanthogranulomatouspyelonephritis, which is a chronic infection associated with the formation of calculi. Gallstones are present in most patients with XGC.Presents sonographically as diffuse or focal thickening of the gallbladder wall, with mural nodularity. The hypoechoic nodules or bands within the thickened wall may be seen suggesting the diagnosis.Because the hepatic surface of the gallbladder lacks a serosal layer, the inflammatory process more easily extends to the adjacentliver, and the liver–gallbladder margin is frequently indistinct.
  32. Gall-bladder polyps are usually asymptomatic but may cause biliary colic.Gall-bladder polyps are usually discovered incidentally by transabdominalultrasonography, because they are so commonly asymptomatic.The primary limitation of ultrasonography is its inability to distinguish benign from malignant polyps, particularly when there are concomitant gall stones within the gall bladder and when the polyp is &gt; 10 mm in diameter.
  33. Cholesterol polyps are more common in women, at least until age 60, and have no malignant potential.The mechanism of formation of cholesterol polyps is unknown and they are found in association with gall stones only in the minorityof patients.
  34. For a polyp &gt; 18 mm, open surgery is recommended: the polyp is highly likely to be a locally invasive malignancy, and should be staged preoperatively with CT or EUS.
  35. Heterogeneous” was defined as a gallbladder polyps pattern with mixed echogenicity not including hyperechoic spot(s).
  36. Has been postulated to result from mechanical obstruction of the gallbladder (from stones, cystic duct kinking, or congenital septum), chronic inflammation, and anomalous pancreaticobiliaryductal union.The association of this disorder with clinical findings is controversial. More than 90% of cases are associated with gallstones, which may be responsible for biliary symptoms.There is also a higher frequency of gallbladder carcinoma in gallbladders with segmental adenomyomatosis than in those without segmental adenomyomatosis.The epithelium and muscular layers proliferate, and invagination of the epithelial-lined spaces into the gallbladder wall produce intramural diverticula, termed Rokitansky-Aschoff sinuses. These may accumulate bile, cholesterol crystals, or even stones.
  37. On US examinations they may be anechoic if large enough and bile containing but more frequently are small and contain cholesterol, biliary sludge, or gallstones that create echogenic foci, often with ring-down or comet tail artifacts. If the diverticula and their associated artifacts are not present, nonspecific mural thickening indistinguishable from acute or chronic cholecystitis and gallbladder carcinoma may be present.
  38. These foci are caused by the cholesterol crystals within RASs.String: خيط – سلك - حبلpearls: لؤلؤ
  39. In one sonographic series, half the patients with these early carcinomas had no protruding lesions, and fewer than one-third were identified preoperatively.