Diagnostic Ultrasound - Abdomen and Pelvis

Diffuse Gallbladder Wall Thickening
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Differential Diagnoses: Biliary System
DIFFERENTIAL DIAGNOSIS
Common
• Acute Calculous Cholecystitis
• Chronic Cholecystitis
• Hyperplastic Cholecystosis (Adenomyomatosis)
• Wall Thickening due to Systemic Diseases
○ Congestive Heart Failure
○ Renal Failure
○ Hepatic Cirrhosis
○ Hypoalbuminemia
Less Common
• Acute Acalculous Cholecystitis
• Acute Pancreatitis
• Acute Hepatitis
• Perforated Peptic Ulcer
• Gallbladder Carcinoma
• Lymphoma
• AIDS-Related Cholangiopathy
• Gallbladder Varices
Rare
• Xanthogranulomatous Cholecystitis
• Dengue Fever
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
• Clinical information is essential to derive differential
diagnosis
• Presence of sepsis and right upper quadrant (RUQ) pain
favor acute cholecystitis
• Presence of known systemic diseases: Congestive heart
failure, renal failure, hypoalbuminemia are important
considerations
• Presence of regional disease: Acute hepatitis or
pancreatitis, cirrhosis affect gallbladder wall
• Known malignancy
Other Info
• Fever, leucocytosis, liver function tests
Helpful Clues for Common Diagnoses
• Acute Calculous Cholecystitis
○ Clinical: RUQ pain, fever, positive Murphy sign
○ Acute gallbladder (GB) inflammation secondary to
calculus obstructing cystic duct
○ Gallstones ± impaction in GB neck
○ Diffuse GB wall thickening (> 3 mm)
– Striated appearance: Alternating bright and dark
bands within thick GB wall
– GB wall lucency "halo" sign: Sonolucent middle layer
due to edema
○ Distended gallbladder (GB hydrops)
○ Positive sonographic Murphy sign
○ Presence of pericholecystic fluid
○ Complicated cholecystitis
– Gangrenous cholecystitis
□ Asymmetric wall thickening
□ Marked wall irregularities
□ Intraluminal membranes
– GB perforation
□ Defect in GB wall
□ Pericholecystic abscess or extraluminal stones
– Emphysematous cholecystitis
□ Gas in GB wall/lumen
– Empyema of GB
□ Intraluminal echoes, purulent exudate/debris
• Chronic Cholecystitis
○ Mostly asymptomatic
○ Diffuse GB wall thickening
– Mean thickness ~ 5 mm
– Smooth/irregular contour
○ Contracted GB
– GB lumen may be obliterated in severe cases
○ Presence of gallstones in nearly all cases
• Hyperplastic Cholecystosis (Adenomyomatosis)
○ Adenomyomatosis of GB
○ Clinically asymptomatic, usually incidental US finding
○ Focal or diffuse GB wall thickening
○ Tiny echogenic foci in GB wall producing "comet-tail"
artifacts
○ Presence of cystic spaces within GB wall
○ Fundal adenomyomatosis: Smooth thickening or focal
mass in fundal region ± ring down artifact
○ Hourglass GB: Narrowing of mid portion of GB
• Wall Thickening due to Systemic Diseases
○ Clinical correlation is key to explain presence of GB wall
thickening
○ Appearance of wall thickening is nonspecific
○ Other ancillary US findings
– Congestive heart failure: Engorged hepatic veins and
IVC, diffuse hypoechoic liver echo pattern
– Renal failure: Small kidneys with increased
parenchymal echogenicity
– Hepatic cirrhosis: Coarse liver echo pattern,
irregular/nodular liver contour, signs of portal
hypertension (e.g., ascites, splenomegaly, varices)
– Hypoalbuminemia: Presence of ascites, diffuse bowel
wall thickening
Helpful Clues for Less Common Diagnoses
• Acute Acalculous Cholecystitis
○ More commonly seen in critically ill patients (e.g., post
major surgery, severe trauma, sepsis, etc.)
○ US features are similar to acute calculous cholecystitis
except for absence of impacted gallstone
– GB wall thickening: Hypoechoic, layered/striated
appearance
– GB distension: Often filled with sludge
– Positive sonographic Murphy sign
– Pericholecystic fluid
• Acute Pancreatitis
○ Spread of inflammation to GB fossa
○ Nonspecific GB wall thickening
○ Diffuse/focal, swollen, hypoechoic pancreas
• Acute Hepatitis
○ Clinical history: General malaise, vomiting, deranged liver
function test with hepatitic pattern
○ Hepatomegaly with diffuse decrease in echogenicity