Gallbladder wall thickening

Adriaan C. van Breda Vriesman, Robin Smithuis, Dries van Engelen and
Julien B.C.M. Puylaert
Radiology Department of the Rijnland Hospital, Leiderdorp; the Groene Hart Hospital, Gouda and the
Medical Centre Haaglanden, the Hague, the Netherlands

Publicationdate 2006-02-01

Thickening of the gallbladder wall is a relatively frequent finding at diagnostic imaging studies.

Historically, a thick-walled gallbladder has been regarded as proof of primary gallbladder disease,
and it is a well-known hallmark feature of acute cholecystitis.

The finding itself, however, is non-specific and can be found in a wide range of gallbladder diseases
and extracholecystic pathological conditions.

In this review we discuss and illustrate the various causes of a generalized thickened gallbladder
wall.

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Introduction
Normal gallbladder
Thickened gallbladder wall
Differential diagnosis of gallbladder wall thickening
Primary gallbladder disease
Acute cholecystitis
Acalculous cholecystitis
Chronic cholecystitis
Xanthogranulomatous cholecystitis
Porcelain gallbladder
Gallbladder carcinoma
Adenomyomatosis
Secondary gallbladder involvement
Liver cirrhosis
Hepatitis
Congestive right heart failure
Pancreatitis
Conclusion

Introduction
Distended hydropic and hyperemic gallbladder in acute cholecystitis due to stone obstruction in the gallbladder neck
or cystic duct.

Sonography, CT and MRI all allow direct visualization of the normal and thickened gallbladder wall.

Traditionally, sonography is used as the initial imaging technique for evaluating patients with sus-
pected gallbladder disease, because of its high sensitivity in the detection of gallbladder stones, its
real-time character, speed and portability [1].

However, CT has become popular for evaluating the acute abdomen and often is the first modality to
detect gallbladder wall thickening [2], or it may be used as an adjunct to an inconclusive sonography
or for staging of disease.

The potential value of MRI in the evaluation of gallbladder pathology has been shown [3], but it still
plays little role.
LEFT: US of a normal gallbladder after an overnight fast shows the wall as a pencil-thin echogenic line
(arrow).RIGHT: US in the postprandial state shows pseudothickening of the gallbladder

Normal gallbladder
The normal gallbladder wall appears as a pencil-thin echogenic line at sonography.

The thickness of the gallbladder wall depends on the degree of gallbladder distention and pseudoth-
ickening can occur in the postprandial state.

Contrast-enhanced CT shows the normal gallbladder wall as a thin rim of enhancing soft-tissue

The normal gallbladder wall is usually perceptible at CT as a thin rim of soft-tissue density that en-
hances after contrast injection.
LEFT: US in a 59-year-old woman with acute cholecystitis shows the layered appearance of a thickened gallbladder
wall, with a hypoechoic region between echogenic linesRIGHT: At contrast-enhanced CT the thick-walled gallbladder
contains a hypodense outer layer (arrow) due to subserosal oedema

Thickened gallbladder wall

Thickening of the gallbladder wall is a relatively frequent finding at diagnostic imaging studies.

A thickened gallbladder wall measures more than 3 mm, typically has a layered appearance at
sonography [1], and at CT frequently contains a hypodense layer of subserosal oedema that mimics
pericholecystic fluid [2]

Differential diagnosis of gallbladder wall thickening

The differential diagnosis of gallbladder wall thickening is listed on the left.

Diffuse gallbladder wall thickening may produce a diagnostic problem, as it occurs in symptomatic
and asymptomatic patients, and in patients with and without an indication for a cholecystectomy.

Diffuse thickening of the gallbladder wall may occur in patients who do not have a primary gallblad-
der disease, but in whom the gallbladder is secondarily involved in an extrinsic pathological condi-
tion.

In these patients a cholecystectomy is unwarranted, and gallbladder abnormalities will usually return
to normal after correction of its extrinsic cause.
 Primary gallbladder disease

43-year-old woman with acute calculous cholecystitis.Contrast-enhanced CT shows a distended gallbladder

(arrowheads) with a slightly thickened wall and subtle regional fat-stranding (asterix). There is an impacted
obstructing stone in the neck of the gallbladder (arrow).

Acute cholecystitis
Acute cholecystitis is the fourth most common cause of hospital admissions for patients presenting
with an acute abdomen [4], and it is the prime diagnostic concern when a thick-walled gallbladder is
found at imaging.

This feature, however, is not pathognomonic for acute cholecystitis.

Additional imaging signs that support the diagnosis of acute calculous cholecystitis are:

Obstructing gallstone
Hydropical dilatation of the gallbladder
Positive sonographic Murphy's sign ( i.e., pain elicited by pressure over the sonographically
located gallbladder)
Pericholecystic fat inflammation or fluid
Hyperemia of the gallbladder wall at power Doppler.
Acute calculous cholecystitis

On the left images of a 62-year-old man with acute calculous cholecystitis.

Transverse sonogram at the spot of maximum tenderness shows a non-compressible hydropically

distended thick-walled gallbladder (arrowheads), with an intraluminal stone and sludge or debris.

Contrast-enhanced CT depicts extensive fat inflammation (arrowheads) surrounding the

gallbladder
(arrow).

74-year-old man with acute acalculous cholecystitis. LEFT: US at the spot of maximum tenderness shows mural
thickening of the gallbladder (arrow) that is completely filled with sludge (asterix) without any stones. RIGHT: Power-
Doppler sonography shows hypervascularity of the gallbladder wall (arrowhead), as a supporting sign of
inflammation.

Acalculous cholecystitis
Acute acalculous cholecystitis mainly occurs in critically ill patients, presumably due to increased bile
viscosity from fasting and medication that causes cholestasis.

The imaging features are those of acute cholecystitis, except for the absence of stones whereas gall-
bladder sludge is usually present (Fig).

 Because in critically ill patients gallbladder abnormalities are frequently found secondary to systemic
disease (see below), acalculous cholecystitis can be difficult to diagnose [5].

In these patients a percutaneous cholecystostomy can be both diagnostic and therapeutic.

Chronic cholecystitis. Longitudinal sonogram of the gallbladder shows slight wall thickening (arrow) and an
intraluminal non-obstructing stone

Chronic cholecystitis
Chronic cholecystitis is a term used clinically to refer to symptomatic gallbladder stones that cause
transient obstruction, leading to a low-grade inflammation with fibrosis [1].

Correlation of the imaging finding of a stone-containing slightly thick-walled gallbladder with the
clinical history is critical.

On the left images of a 49-year-old woman with chronic cholecystitis.

This patient had fasted overnight, so the wall-thickening does not represent physiologic contraction.

Correlation of these findings with her clinical history of recurrent colic-like right upper quadrant pain,
due to transient gallbladder obstruction, is essential for the diagnosis.
Xanthogranulomatous cholecystitis. LEFT: US shows marked wall thickening with intramural hypoechoic nodules
(arrowheads), and an intraluminal stone (arrow).RIGHT: Contrast-enhanced CT shows a deformed and thickened
gallbladder wall containing hypoattenuating nodules

Xanthogranulomatous cholecystitis
Xanthogranulomatous cholecystitis is an unusual variant of chronic cholecystitis, characterized by a
lipid-laden inflammatory process comparable to xanthogranulomatous pyelonephritis.

Imaging studies show marked gallbladder wall thickening, often containing intramural nodules that
are hypoechoic at sonography and hypoattenuating at CT, representing abscesses or foci of xan-
thogranulomatous inflammation.

These features overlap with those of gallbladder carcinoma, making preoperative distinction between
these entities often impossible [6].
Xanthogranulomatous cholecystitis. Hypoattenuating nodules ( arrowheads) represent abscesses. The lumen contains
several stones (arrow).

On the left a 71-year-old man with xanthogranulomatous cholecystitis.

Contrast-enhanced CT shows a deformed and thickened gallbladder wall containing hypoattenuating

nodules .

These represent abscesses or foci of inflammation.

Porcelain gallbladder.

Porcelain gallbladder
 A porcelain gallbladder is a rare disorder in which chronic cholecystitis produces mural calcification.

In these patients a prophylactic cholecystectomy has been advocated because of its association with
gallbladder carcinoma [4]. However, this association appears to be weak.

LEFT: Gallbladder carcinoma. US shows marked generalized wall thickening (arrowheads), replacing the gallbladder
lumen. Multiple gallbladder stones (arrow) indicate the probable location of the filled lumen.RIGHT: Contrast-
enhanced CT depicts a thick-walled gallbladder (arrowhead), with local infiltration of the mass in the adjacent liver
(arrow).

Gallbladder carcinoma
Gallbladder carcinoma is the fifth most common malignancy of the gastrointestinal tract, and is
found incidentally in 1% to 3% of cholecystectomy specimens [4].

It is often detected at a late stage of the disease, due to lack of early or specific symptoms.

Gallbladder carcinoma has various imaging appearances, ranging from a polypoid intra-luminal le-
sion to an infiltrating mass replacing the gallbladder, and it may also present as diffuse mural thick-
ening.

Associated findings such as invasion of adjacent structures, secondary bile duct dilatation, and liver
or nodal metastases may help in differentiating a carcinoma from acute or xanthogranulomatous
cholecystitis [2, 4].

In absence of these associated findings, it may not be possible to differentiate a carcinoma from
xanthogranulomatous cholecystitis.
Adenomyomatosis in a 39-year-old woman. US shows mural thickening with calcifications with the characteristic
'comet-tail' reverberation artifact (arrow) due to small cholesterol crystals within Rokitansky-Aschoff sinuses.

Adenomyomatosis
Adenomyomatosis of the gallbladder is characterized by epithelial proliferation, muscular hyper-
trophia and intramural diverticula (Rokitansky-Aschoff sinuses), which may segmentally or diffusely
involve of the gallbladder.

It is a benign condition that requires no specific treatment, occurring as an incidental finding in up to

9% of cholecystectomy specimens [6].

The sonographic finding of cholesterol crystals, shown as 'comet-tail'

reverberation artifacts (Fig),
within a thickened wall of the gallbladder strongly suggests this diagnosis.

Air may produce a similar artifact, however, patients with emphysematous cholecystitis are usually ill
in contrast to those with adenomyomatosis.

MR imaging may be able to differentiate adenomyomatosis from gallbladder carcinoma by depicting

Rokitansky-Aschoff sinuses [7].

Secondary gallbladder involvement

56-year-old man with liver cirrhosisLEFT: US depicts wall thickening (arrow), surrounded by ascites. Note the
irregular cirrhotic liver parenchyma. RIGHT: At contrast-enhanced CT the wall of the gallbladder (arrow) appears
nearly normal, because subserosal oedema can not be well differentiated from surrounding ascites at CT.

Liver cirrhosis
Systemic diseases such as hepatic dysfunction, heart failure, or renal failure may lead to diffuse gall-
bladder thickening [1, 2].

The exact pathophysiologic mechanism leading to oedema of the gallbladder wall in these diverse
conditions is uncertain, but it is likely due to elevated portal venous pressure, elevated systemic ve-
nous pressure, decreased intravascular osmotic pressure, or a combination of these factors.

Hypoproteinemia has also been reported as a cause of extrinsic gallbladder disease, but this has
been disputed [8].

Liver cirrhosis, hepatitis and congestive right heart failure are relatively frequent causes.
The case
on the left is a patient with liver cirrhosis.

The secondary gallbladder wall thickening is presumably due to elevated portal venous pressure and
decreased intravascular osmotic pressure.
Drug-induced hepatitis with diffuse gallbladder wall thickening

Hepatitis
On the left a 75-year-old man with drug-induced hepatitis.

Longitudinal sonogram of a non-distended gallbladder shows diffuse wall thickening (arrow), and in-
cidental cholelithiasis which may be confusing.

Drug-induced hepatitis.
 In the same patient with the drug-induced hepatitis MR images were obtained to evaluate the bile
ducts because of abnormal liver function tests.

On the far left Axial SPIR T2-weighted image (A) shows a small amount of ascites (arrowhead)
which indicates that the thickened gallbladder wall (arrow) probably has an extrinsic systemic cause.
Next to it an oblique HASTE image for MR cholangiography that excludes choledocholithiasis.

Mural thickening of the gallbladder (arrowhead) is also shown.

Diffuse gallbladder wall thickening in congestive right heart failure

Congestive right heart failure

On the left a 74-year-old man with congestive right heart failure.

Ultrasound depicts diffuse wall thickening of a stone-free painless gallbladder and large-caliber he-
patic veins (arrowheads) and inferior vena cava, as supporting evidence of right heart failure.

Pancreatitis in a 56-year-old man Contrast-enhanced CT shows peripancreatic inflammatory changes (arrowheads),

and thickening of the wall of the gallbladder (arrow) which is secondarily involved in the pancreatic inflammation.

Pancreatitis
Extracholecystic inflammation may secondarily involve the gallbladder causing wall thickening, due
to direct spread of the primary inflammation, or less frequently due to an immunologic reaction [8].

Theoretically, it may be caused by any inflammation that extends to the region of the gallbladder,
but only few are regularly encountered including hepatitis, pancreatitis (Figure), and pyelonephritis.

Gallbladder wall thickening has also been reported in patients with infectious mononucleosis [9], and
in patients with AIDS due to opportunistic infections or secondary neoplastic infiltration [2].

Conclusion

Diffuse gallbladder wall thickening can result from a broad spectrum of pathological conditions, in-
cluding surgical and non-surgical diseases.

At times a definite imaging diagnosis may be impossible.

In most cases however, the cause can be determined by correlation of the associated imaging find-
ings with the clinical presentation.

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