Diagnostic Ultrasound - Abdomen and Pelvis

Acute Calculous Cholecystitis
Diagnoses: Biliary System
TERMINOLOGY
• Acute inflammation of gallbladder (GB) secondary to
calculus obstructing cystic duct
IMAGING
• Distended GB (> 5 cm transverse diameter)
• Gallstones ±impaction in GB neck or cystic duct
• Diffuse GB wall thickening (> 4-5 mm)
• Hazy delineation of GB wall with echogenic pericholecystic
fat
• Positive sonographic Murphy sign: Pain and tenderness
with transducer pressure directly over gallbladder
• US is first-line imaging tool
• HIDA after equivocal US, more sensitive than US
• CT and MR for complicated cholecystitis
• Gangrenous cholecystitis: Asymmetric wall thickening,
marked wall irregularities, intraluminal membranes
• Gallbladder perforation: Defect in GB wall with
pericholecystic abscess or extraluminal stones
KEY FACTS
• Emphysematous cholecystitis: Gas in GB wall/lumen
• Empyema of gallbladder: Highly reflective intraluminal
echoes without shadowing, purulent exudate/debris
• Move patient to confirm impacted GB stone, assess Murphy
sign and surrounding area
CLINICAL ISSUES
• May progress to gangrenous cholecystitis and perforation if
untreated
DIAGNOSTIC CHECKLIST
• Combination of gallstones, wall thickening, and positive
Murphy sign increase specificity
• Possibility of adjacent inflammatory disease such as
perforated ulcer, acute hepatitis, or acute pancreatitis
mimicking acute cholecystitis
(Left) Left lateral decubitus
ultrasound shows a shadowing
stone in the neck of the
gallbladder ſt. Note the thick
wall with subserosal edema
st. Murphy sign was positive.
(Right) Left lateral decubitus
ultrasound shows a
shadowing stone in the
fundus of the gallbladder.
Note the thick wall with
subserosal edema ſt.
(Left) Transverse ultrasound
shows dependent shadowing
gallstones with a sludge
level ſt. Note the thickened
gallbladder wall with a central
hypoechoic halo st. (Right)
Axial contrast-enhanced CT of
acute calculous cholecystitis
shows a thick-walled
gallbladder st containing
calcified gallstones ſt.
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