Diagnostic Ultrasound - Abdomen and Pelvis

Diffuse Gallbladder Wall Thickening
○ "Starry sky" appearance: Increased echogenicity of portal
triad walls against hypoechoic liver parenchyma
○ Periportal hypo-/anechoic area
○ Gallbladder lumen less dilated than in acute cholecystitis
• Perforated Peptic Ulcer
○ Penetrating ulcer in duodenal wall causes sympathetic
GB wall thickening
○ Presence of extraluminal fluid/gas
• Gallbladder Carcinoma
○ Asymmetric or irregular GB wall thickening
○ Mass replacing GB with locally advanced tumor
○ Presence of gallstones
○ Invasion of adjacent structures (e.g., liver, duodenum)
○ Regional nodal and liver metastases
• Lymphoma
○ Rare involvement of GB by secondary lymphoma
○ Nonspecific diffuse GB wall thickening
○ Presence of intraabdominal lymphomatous lymph nodes
• AIDS-Related Cholangiopathy
○ Biliary inflammatory lesions caused by AIDS-related
opportunistic infections leading to biliary
stricture/obstruction or cholecystitis
○ Diffuse GB wall thickening
○ Bile duct wall thickening/inflammation
– Periductal hyper-/hypoechoic areas
○ Focal biliary stricture and dilatation
• Gallbladder Varices
○ Usually seen in portal hypertension or cavernous
transformation of main portal vein
○ Tubular structures in GB wall readily confirmed with
color/power Doppler and pulsed Doppler
• Xanthogranulomatous Cholecystitis
○ Rare form of chronic cholecystitis
○ Diffuse irregular wall thickening, may appear infiltrative;
mimics GB carcinoma
• Dengue Fever
○ Rash, fever, headache and joint pains after travel to
endemic area
○ GB thickening from acute viral hepatic infection leading
to hepatic failure
Alternative Differential Approaches
• Etiology of GB wall thickening
○ Inflammatory conditions
– Acute calculous cholecystitis
– Acute acalculous cholecystitis
– Chronic cholecystitis
– AIDS-related cholangiopathy
– Secondary causes: Acute hepatitis, perforated peptic
ulcer, pancreatitis
○ Systemic diseases
– Congestive heart failure
– Renal failure
– Liver cirrhosis
– Hypoalbuminemia
○ Neoplastic infiltration
– GB carcinoma
– Leukemic/lymphomatous infiltration
SELECTED REFERENCES
1. Garg PK et al: Xanthogranulomatous Inflammation of Gallbladder and Bile
Duct Causing Obstructive Jaundice Masquerades Gallbladder Cancer: a
Formidable Diagnostic Challenge Continues. J Gastrointest Cancer. ePub,
2014
2. Runner GJ et al: Gallbladder wall thickening. AJR Am J Roentgenol.
202(1):W1-W12, 2014
3. Zemour J et al: Gallbladder tumor and pseudotumor: Diagnosis and
management. J Visc Surg. 151(4):289-300, 2014
4. Teefey SA et al: Acute cholecystitis: do sonographic findings and WBC count
predict gangrenous changes? AJR Am J Roentgenol. 200(2):363-9, 2013
5. Charalel RA et al: Complicated cholecystitis: the complementary roles of
sonography and computed tomography. Ultrasound Q. 27(3):161-70, 2011
6. O'Connor OJ et al: Imaging of cholecystitis. AJR Am J Roentgenol.
196(4):W367-74, 2011
7. Ito K et al: Imaging findings of unusual intra- and extrahepatic portosystemic
collaterals. Clin Radiol. 64(2):200-7, 2009
8. Furlan A et al: Gallbladder carcinoma update: multimodality imaging
evaluation, staging, and treatment options. AJR Am J Roentgenol.
191(5):1440-7, 2008
9. van Breda Vriesman AC et al: Diffuse gallbladder wall thickening: differential
diagnosis. AJR Am J Roentgenol. 188(2):495-501, 2007
10. Levy AD et al: Gallbladder carcinoma: radiologic-pathologic correlation.
Radiographics. 21(2):295-314; questionnaire, 549-55, 2001
Differential Diagnoses: Biliary System
Acute Calculous Cholecystitis
Congestive Heart Failure
(Left) Longitudinal oblique
ultrasound of acute calculous
cholecystitis shows an
impacted stone in the
gallbladder neck. There is
diffuse edema and thickening
of the gallbladder wall st.
(Right) Longitudinal oblique
ultrasound shows diffuse
gallbladder wall edema
secondary to heart failure.
There is striated wall
thickening st and a fold in the
gallbladder neck .
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