Acute Uncomplicated Cholecystitis

● Gallbladder wall thickening (> 3–5 mm), mural or mucosal hyperenhancement, pericholecystic fluid and
adjacent soft-tissue inflammatory stranding, abnormally increas-ed gallbladder distention, and
cholelithiasis may be observed on CT in the setting of acute cholecystitis (Fig. 1B)
● On occasion, when medical man-agement fails or surgery is contraindicated, acute cholecystitis may
be treated with percuta-neous catheter drainage to decrease intraluminal pressure and decrease the
risk of gallbladder perforation (Fig. 1C)
Acute Complicated Cholecystitis
Gangrenous Cholecystitis and Gallbladder Perforation

● Gangrenous change may occur in the setting of

advanced acute cholecystitis
● Sonographic findings suggesting gangrenous change
include floating intraluminal membranes
(representing sloughed mucosa), echogenic
shadowing foci consistent with gas within the
gallbladder wall or lumen, frank disruption of the
gallbladder wall, and pericholecystic abscess
formation
● Small areas of gallbladder perforation may be difficult
to detect on imaging. A focal defect in the gallbladder
wall may be visualized on sonography, CT, or MRI.
● An extraluminal gallstone is a specific imaging finding
that indicates perforation (Fig. 2).
● More often, findings of perforation are nonspecific
and include pericholecystic fluid, gallbladder lumen
collapse, and pericholecystic abscess
Acute Complicated Cholecystitis
Emphysematous Cholecystitis

● Emphysematous cholecystitis is defined as the

presence of gas within the gallbladder wall or lumen
in the setting of acute cholecystitis without
demonstrable abnormal fistulous communication
between the gallbladder and the gastrointestinal
tract.
● Emphysematous cholecystitis may be diagnosed
initially using abdominal radiography.
● Radiographs that reveal curvilinear lucencies within
the gallbladder wall or an air–fluid level within the
gallbladder lumen are specific for this entity in the
setting of suspected cholecystitis (Fig. 3A)
● Sonography findings curvilinear or punctate
hyperechoic foci, often with reverberation artifact
(also known as ringdown artifact) are present,
corresponding to foci of gas within the gallbladder
wall or lumen (Fig. 3B).
Acute Complicated Cholecystitis
Emphysematous Cholecystitis

● CT is considered the most sensitive and specific imaging technique for the diagnosis of emphysematous
cholecystitis.
● CT shows low-attenuation foci consistent with gas within the gallbladder wall or lumen (Fig. 4)
Acute Complicated Cholecystitis
Suppurative Cholecystitis
● Suppurative cholecystitis (gallbladder empyema)
may occur as a complication of acute cholecystitis.
This condition results when purulent material fills
and distends the gallbladder lumen

Hemorrhagic Cholecystitis
● Hemorrhage into the gallbladder wall and lumen
may be observed in the setting of acute calculous or
acalculous cholecystitis
● Hemorrhagic cholecystitis typically presents on
sonography and CT with imaging findings
suggestive of acute cholecystitis. In addition,
sonography may show echogenic or heterogeneous
material within the gallbladder wall or lumen
because of hemorrhage. On CT, high-attenuation
blood products are present within the gallbladder
wall or lumen [1, 26] (Fig. 5)
Acute Complicated Cholecystitis
Acalculous Cholecystitis

● Acalculous cholecystitis is most often observed in the critically ill population, including postoperative and trauma
patients in an ICU setting as well as those patients receiving total parenteral nutrition
● This condition is thought to be caused by a gradual increase in bile viscosity that leads to eventual functional
obstruction of the cystic duct
● Common sonographic findings include abnormally increased gallbladder distention, gallbladder wall thickening (> 3–5
mm), pericholecystic fluid (in the absence of ascites), and sludge (in the absence of cholelithiasis) (Fig. 6).
● CT may reveal similar imaging findings as well as pericholecystic inflammatory stranding with adjacent liver hyperemia
Chronic Cholecystitis

● Patients may have a history of recurrent acute

cholecystitis or biliary colic, although some patients
may be asymptomatic
● The most commonly observed cross-sectional
imaging findings in the setting of chronic
cholecystitis are cholelithiasis and gallbladder wall
thickening (Fig. 7).
● The gallbladder may appear contracted or
distended, and pericholecystic inflammation is
usually absent
Chronic Cholecystitis

● Possible complications related to chronic cholecystitis

include acute cholecystitis and gallbladder
carcinoma. An uncommon complication is the
formation of a biliary–enteric fistula.
● This can lead to passage of gallstones into the small
bowel with resultant obstruction, also known as
gallstone ileus
● Radiographically, the diagnosis can be made by
identifying the Rigler’s radiographic triad, which
includes pneumobilia, an ectopic gallstone, and
evidence of bowel obstruction (Fig. 8)
● This combination of imaging findings, however, is
seen in a minority of patients with gallstone ileus
Xanthogranulomatous
Cholecystitis

● Xanthogranulomatous cholecystitis is a rare

gallbladder inflammatory disorder characterized by
abnormal intramural nodules.
● Cholelithiasis and gallbladder wall thickening are the
most common findings on sonography and CT in
patients with xanthogranulomatous cholecystitis.
● Mural thickening may be focal or diffuse.
● Pericholecystic inflammatory changes may also be
present.
● Intramural hypoechoic (on sonography) or
hypoattenuating (on CT) nodules or bands may
suggest the specific diagnosis of
xanthogranulomatous cholecystitis.
● The diagnosis is rarely made before surgery and
histopathologic evaluation of the gallbladder (Fig. 9).
Mirizzi Syndrome
● Mirizzi syndrome may occur as an acute
presentation of cholelithiasis or in the setting
of acute cholecystitis.
● The condition occurs when an impacted
gallstone in the gallbladder neck or cystic duct
causes biliary tree obstruction and
cholestasis.
● Cholestasis is the result of either direct
compression of the adjacent common hepatic
duct or secondary local inflammation causing
bile duct wall edema and fibrosis
● Sonography and CT findings observed in
Mirizzi syndrome include the presence of a
gallstone located within the gallbladder neck
or cystic duct and dilatation of the common
hepatic duct and the more proximal
intrahepatic bile ducts (Fig. 10).
● Additional findings may include normal caliber
of the common bile duct, pericholecystic and
peribiliary ductal inflammatory changes, and
gallbladder wall thickening
Gallbladder Volvulus
● Gallbladder volvulus is a rare condition in which variation in normal mesenteric anatomy allows the gallbladder to
twist on itself
● On torsion, gallbladder venous drainage becomes obstructed and ischemia ensues. Torsion may be complete (>
180°) or incomplete (< 180°).
● The majority of patients with this condition are elderly women.
● Imaging findings compatible with gallbladder torsion on sonography and CT include abnormal orientation of the
gallbladder, abrupt tapering of the cystic duct, pericholecystic inflammatory changes, and abnormally increased
luminal distention (Fig. 11)
● Inflammatory changes involving the gallbladder may be
observed in patients with clinical and laboratory findings of Acute Hepatitis-Related
Gallbladder Changes
acute hepatitis, regardless of the underlying cause.
● Such gallbladder changes are most commonly thought to
be reactive because of adjacent hepatic inflammation.
● Sonography findings observed in the setting of acute
hepatitis include marked gallbladder wall thickening,
gallbladder contraction, and echogenic bile(Fig. 12).
● The gallbladder wall may also show three distinct layers
with central hypoechogenicity.
● The adjacent liver may show findings suggestive of
diffuse edema, including hypoechoic parenchyma with
prominent echogenic portal triads (the so-called starry-sky
appearance), although this appearance is uncommon.
● CT may show diffuse gallbladder wall thickening
Polypoid Lesions of the
Gallbladder: Disease
Spectrum with Pathologic
Correlation
GIT-2
Imaging Protocols Gallbladder
polyps
● Lesions should be imaged in more than
one position (eg, supine and left decubitus)
to avoid mistaking mobile sludge balls for
polypoid lesions (Fig 1).
● It is important to note the size and shape
(eg, pedunculated or sessile) of a polypoid
lesion and the presence of gallstones,
which increase the likelihood that the polyp
is a neoplastic lesion.
● Other findings to note include gallbladder
wall thickening adjacent to the polypoid
lesion, multiple polyps, biliary strictures,
and hepatic masses.
● The presence of twinkling artifact may help
diagnose adenomyomatosis
Mimics of Gallbladder Polyps

● Adherent gallstones and gallbladder sludge

may be immobile and mimic true
gallbladder polyps.
● The characteristic acoustic shadowing of
gallstones may be difficult to visualize in
obese patients or when calculi are deep in
the gallbladder neck.
● Gallbladder sludge is usually easy to
diagnose and is seen as mobile small
intraluminal, hyperechoic, nonshadowing,
nonvascular balls.
● However, adherent, tumefactive sludge
may appear as a mass lesion (Fig 2).
Classification of Gallbladder Polyps
● Gallbladder polyps may be classified as pseudotumors, benign tumors, or malignant
tumors.

Pseudotumors

● Cholesterol polyps, adenomyomatosis, and inflammatory polyps, in that order of frequency, constitute the major polypoid
pseudotumors.
● Cholesterol polyps and adenomyomatosis are hyperplastic noninflammatory conditions with different histologic features.
● The gallbladder wall is composed of four layers: mucosa, lamina propria, muscularis propria, and serosa. It does not
have a muscularis mucosae or a submucosa layer
● The wall thickening that occurs in adenomyomatosis involves hyperplasia of both the mucosa and muscularis propria.
● In adenomyomatosis, cholesterol accumulation is intraluminal, and crystals precipitate in bile trapped in intramural
diverticula (RokitanskyAschoff sinuses) lined by the epithelial layer of the mucosa.
● Gallbladder wall thickening and intramural diverticula containing cholesterol crystals, or calculi, are pathognomonic of
adenomyomatosis
Cholesterol Polyps

● Deposition of triglycerides and cholesterol esters within

macrophages in the lamina propria, and the polyp is
covered by normal epithelium.
● At US, cholesterol polyps appear as small, round,
smoothly contoured, intraluminal lesions that are attached
to the wall. The stalk is rarely seen, an appearance that
gives rise to the “ball on the wall” sign (Fig 3).
● Cholesterol polyps are usually echogenic with no acoustic
shadowing; however, particularly when multiple cholesterol
polyps are confluent and/or larger than 1 cm, they cannot
be definitively differentiated from other benign or
malignant lesions at imaging.
Adenomyomatosis

● Imaging findings of adenomyomatosis parallel its

histologic features: intramural diverticula that may be filled
with inspissated bile and appear as multiple small cystic
spaces that are anechoic at US.
● When the intramural diverticula contain sludge, stones, or
papillary projections, they appear echogenic with multiple
acoustic interfaces at US, creating twinkling or comet-tail
artifacts .
● The cystic spaces may be visible at CT, which can help
differentiate between fundal adenomyomatosis and
gallbladder carcinoma.
● At MR imaging, the Rokitansky-Aschoff sinuses cause a
“pearl necklace” sign of multiple round spaces that are
hyperintense on T2-weighted images, a finding that has
been reported to have 92% specificity for
adenomyomatosis (Fig 4)
Inflammatory Polyps

● Inflammatory polyps represent 10% of all gallbladder

polyps in surgical series and are usually multiple and
small, measuring less than 10 mm in diameter
● Little is known about the imaging features of inflammatory
polyps.
● Case reports have described a relatively wide range of US
appearances, including iso- and hypoechogenicity, as well
as hyperechogencitiy, both focally within and surrounding
the lesion
● At US, inflammatory polyps have a nonspecific
appearance.
● A diagnosis of inflammatory polyps may not be made with
certainty at imaging (Fig 5).
Tumorous Polyps
● The most important considerations are epithelial
lesions, adenoma, and adenocarcinoma

Adenomas

● At US, gallbladder adenomas may vary in size (up to 20

mm), have a sessile or pedunculated appearance,
demonstrate internal vascularity at color Doppler
interrogation, and are typically solitary.
● At CT and MR imaging, gallbladder adenomas typically
demonstrate enhancement similar to that of
adenocarcinoma (Fig 6).
● Adenomas cannot be reliably differentiated from
polypoid gallbladder adenocarcinoma at imaging.
Tumorous Polyps ● The most important considerations
are epithelial lesions, adenoma,
and adenocarcinoma
Adenocarcinoma

● The most common malignant gallbladder polyp is primary adenocarcinoma of the gallbladder
● Chronic gallbladder inflammation may also lead to wall calcification—the so-called porcelain gallbladder—which is
associated with gallbladder cancer.
● Other risk factors for gallbladder cancer include PSC, anomalous pancreaticobiliary ductal union, and most types of
choledochal cysts
● In patients with PSC, a substantial number (60%) of gallbladder polyps are malignant (Fig 7)
Tumorous Polyps
Adenocarcinoma

● Gallbladder adenocarcinoma most commonly

manifests as a mass in the gallbladder fossa, with
engulfed gallstones or irregular eccentric gallbladder
wall thickening at imaging.
● US clues to a polypoid gallbladder carcinoma include
a solitary polyp larger than 10 mm, a wide polyp
base, focal wall thickening of more than 3 mm, and
coexisting gallstones (Fig 8)
● At color and spectral Doppler US, linear color signal
at the polyp base and an increased resistive index
may indicate a cancerous polyp.
● Diffuse or branched enhancement and an abruptly
rising, persistent time-intensity enhancement curve at
contrast-enhanced US have been associated with
malignant gallbladder lesions
● FDG PET → used for staging in the setting of a
known carcinoma, FDG uptake within a gallbladder
polyp greater than that in the background liver is an
indication of malignancy (Fig 8)
Tumorous Polyps
Adenocarcinoma

● Enhancement characteristics of gallbladder polyps at

MR imaging, such as early prolonged enhancement
without washout, which is more common in malignant
lesions than in benign lesions, may be useful.
● Several studies have indicated that, at diffusion-
weighted imaging (DWI), malignant gallbladder
lesions tend to have a lower apparent diffusion
coefficient (ADC) than do benign lesions (Fig 9)
Tumorous Polyps
Metastatic Disease and Lymphoma

● Metastases to the gallbladder can occur with any

primary malignancy and typically do so in the setting
of widespread metastatic disease.
● In the western medical literature, the most common
primary tumor to metastasize to the gallbladder is
melanoma, which represents 60% of all gallbladder
metastases (Fig 10).
● In the Asian medical literature, the most common
source of gallbladder metastases is gastric cancer
Tumorous Polyps
Metastatic Disease and Lymphoma

● Cancers of the kidney and lung may hematogenously

spread to the gallbladder, whereas hepatocellular
carcinoma and cholangiocarcinoma may directly
invade the gallbladder (Fig 11).
● Lymphoma of the gallbladder is rare and occurs
either as a primary tumor or, more commonly, as a
result of secondary involvement of the gallbladder by
adjacent lymphadenopathy.
● Because lymphoid tissue is not normally found in the
gallbladder wall, it has been suggested that primary
gallbladder lymphoma arises in the setting of chronic
inflammation
● The most common subtypes of lymphoma involving
the gallbladder are diffuse large B-cell and
mucosaassociated lymphoid tissue (MALT)
lymphoma.
Management Algorithm

● Large degree of overlap in the appearances of

benign and potentially malignant gallbladder lesions.
● According to the management algorithm, which was
determined by a review of the literature, management
of gallbladder polyps primarily relies on the size of the
lesion (Fig 12)
● Two large series confirmed that a size larger than 10
mm is the best indicator of malignancy and warrants
cholecystectomy
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