Diagnostic Ultrasound - Abdomen and Pelvis
Hyperechoic Gallbladder Wall Porcelain Gallbladder Porcelain Gallbladder (Left) Oblique transabdominal ultrasound shows curvilinear echogenicity ſt in the gallbladder wall casting dense posterior acoustic shadowing . Absence of wall-echoshadow sign suggests porcelain gallbladder. (Right) Axial CECT of the same patient confirms the thin diffuse gallbladder wall calcification ſt in a contracted gallbladder. Differential Diagnoses: Biliary System Gas-Filled Duodenal Bulb Hyperplastic Cholecystosis (Left) Transverse ultrasound shows the duodenal bulb containing gas . The gallbladder contains sludge in this patient with ascites st and cirrhosis. The duodenum may be mistaken for a gallbladder. (Right) Transverse oblique ultrasound shows multiple areas of "comet tail" artifact st emanating from the thick wall of the gallbladder. Reverberation artifact is noted from bowel and there is ascites ſt in this patient with chronic liver disease. Emphysematous Cholecystitis Iatrogenic: Post Endoscopic Retrograde Cholangiopancreatography (ERCP) (Left) Longitudinal ultrasound shows the gallbladder fundus in a diabetic patient with fever and right upper quadrant pain. A linear bright echo ſt within a thick wall produces dirty shadowing st that is highly suggestive of gas. This was confirmed with CT. Surgery was performed for emphysematous cholecystitis. (Right) Transverse oblique ultrasound shows a bright linear echo with dirty shadowing ſt representing gas in the gallbladder fundus post ERCP. The gallbladder st was normal. 907
Focal Gallbladder Wall Thickening/Mass Differential Diagnoses: Biliary System DIFFERENTIAL DIAGNOSIS Common • Gallbladder Cholesterol Polyp • Hyperplastic Cholecystosis (Adenomyomatosis) • Adenomatous Polyp • Adherent Gallstone Less Common • Gallbladder Adenocarcinoma • Adjacent Liver or Colonic Tumor • Metastases to Gallbladder • Other Primary Gallbladder Neoplasms • Gastric or Pancreatic Heterotopia/Foregut Cysts Rare but Important • Xanthogranulomatous Cholecystitis ESSENTIAL INFORMATION Key Differential Diagnosis Issues • Most lesions are benign; key is to detect gallbladder (GB) carcinoma early • Carcinoma: Large irregular soft tissue mass ○ Circumferential or eccentric wall thickening ± internal color flow ○ Ill-defined margin, infiltration of gallbladder wall and adjacent liver parenchyma ○ Presence of regional nodal/liver metastases Helpful Clues for Common Diagnoses • Gallbladder Cholesterol Polyp ○ Multiple, small, nonshadowing lesions with soft tissue echogenicity ○ Smooth in contour, sometimes multilobulated in outline ○ Round or ovoid shape; broad base is attached to gallbladder wall ○ Nonmobile on decubitus positioning ○ Overlying GB wall is intact and normal ○ Cholesterolosis: Diffuse nodular wall thickening from cholesterol deposits • Hyperplastic Cholecystosis (Adenomyomatosis) ○ Tiny echogenic foci within thick GB wall with "comet tail" artifacts ○ Fundal adenomyomatosis: Smooth sessile mass/thickening in fundus – Look for comet tail artifacts/color Doppler twinkling artifact ○ Diffuse adenomyomatosis: Diffuse wall thickening with tiny intramural diverticula ○ Segmental form: Wall thickening of midportion to fundus with hourglass appearance • Adenomatous Polyp ○ Larger size (> 10 mm), solitary lesion ○ Usually pedunculated in appearance Helpful Clues for Less Common Diagnoses • Gallbladder Adenocarcinoma ○ Asymmetric GB wall thickening ○ Intramural polypoid mass protruding into gallbladder lumen ○ Ill-defined infiltrative mass in gallbladder fossa ○ Invasion of adjacent liver parenchyma: Indistinct separation between GB mass and liver capsule ○ Presence of regional nodal/liver metastases ± intratumoral vascularity • Metastases to Gallbladder ○ Most common: melanoma, renal and breast cancer ○ Usually have other metastases ○ Multiple, sessile, hypoechoic, internal color flow • Other Primary Gallbladder Neoplasms ○ Epithelial and nonepithelial benign and malignant tumors such as leiomyoma, leiomyosarcoma Helpful Clues for Rare Diagnoses • Xanthogranulomatous Cholecystitis ○ Irregular gallbladder wall thickening, infiltration into liver ○ Hypoechoic bands or nodules in thick gallbladder wall on ultrasound ○ Coexisting gall stones ○ May be indistinguishable from GB carcinoma (Left) Transverse ultrasound of the gallbladder shows 2 small nondependent cholesterol polyps st as an incidental finding in a patient with lymphoma ſt. (Right) Longitudinal decubitus ultrasound of the gallbladder shows a dependent nonmobile echogenic polyp in the gallbladder neck ſt. The lack of mobility distinguishes this from a nonshadowing calculus, although some calculi are adherent. Gallbladder Cholesterol Polyp Gallbladder Cholesterol Polyp 908
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Focal Gallbladder Wall Thickening/Mass<br />
Differential Diagnoses: Biliary System<br />
DIFFERENTIAL DIAGNOSIS<br />
Common<br />
• Gallbladder Cholesterol Polyp<br />
• Hyperplastic Cholecystosis (Adenomyomatosis)<br />
• Adenomatous Polyp<br />
• Adherent Gallstone<br />
Less Common<br />
• Gallbladder Adenocarcinoma<br />
• Adjacent Liver or Colonic Tumor<br />
• Metastases to Gallbladder<br />
• Other Primary Gallbladder Neoplasms<br />
• Gastric or Pancreatic Heterotopia/Foregut Cysts<br />
Rare but Important<br />
• Xanthogranulomatous Cholecystitis<br />
ESSENTIAL INFORMATION<br />
Key Differential Diagnosis Issues<br />
• Most lesions are benign; key is to detect gallbladder (GB)<br />
carcinoma early<br />
• Carcinoma: Large irregular soft tissue mass<br />
○ Circumferential or eccentric wall thickening ± internal<br />
color flow<br />
○ Ill-defined margin, infiltration of gallbladder wall <strong>and</strong><br />
adjacent liver parenchyma<br />
○ Presence of regional nodal/liver metastases<br />
Helpful Clues for Common Diagnoses<br />
• Gallbladder Cholesterol Polyp<br />
○ Multiple, small, nonshadowing lesions with soft tissue<br />
echogenicity<br />
○ Smooth in contour, sometimes multilobulated in outline<br />
○ Round or ovoid shape; broad base is attached to<br />
gallbladder wall<br />
○ Nonmobile on decubitus positioning<br />
○ Overlying GB wall is intact <strong>and</strong> normal<br />
○ Cholesterolosis: Diffuse nodular wall thickening from<br />
cholesterol deposits<br />
• Hyperplastic Cholecystosis (Adenomyomatosis)<br />
○ Tiny echogenic foci within thick GB wall with "comet tail"<br />
artifacts<br />
○ Fundal adenomyomatosis: Smooth sessile<br />
mass/thickening in fundus<br />
– Look for comet tail artifacts/color Doppler twinkling<br />
artifact<br />
○ Diffuse adenomyomatosis: Diffuse wall thickening with<br />
tiny intramural diverticula<br />
○ Segmental form: Wall thickening of midportion to<br />
fundus with hourglass appearance<br />
• Adenomatous Polyp<br />
○ Larger size (> 10 mm), solitary lesion<br />
○ Usually pedunculated in appearance<br />
Helpful Clues for Less Common Diagnoses<br />
• Gallbladder Adenocarcinoma<br />
○ Asymmetric GB wall thickening<br />
○ Intramural polypoid mass protruding into gallbladder<br />
lumen<br />
○ Ill-defined infiltrative mass in gallbladder fossa<br />
○ Invasion of adjacent liver parenchyma: Indistinct<br />
separation between GB mass <strong>and</strong> liver capsule<br />
○ Presence of regional nodal/liver metastases ±<br />
intratumoral vascularity<br />
• Metastases to Gallbladder<br />
○ Most common: melanoma, renal <strong>and</strong> breast cancer<br />
○ Usually have other metastases<br />
○ Multiple, sessile, hypoechoic, internal color flow<br />
• Other Primary Gallbladder Neoplasms<br />
○ Epithelial <strong>and</strong> nonepithelial benign <strong>and</strong> malignant<br />
tumors such as leiomyoma, leiomyosarcoma<br />
Helpful Clues for Rare Diagnoses<br />
• Xanthogranulomatous Cholecystitis<br />
○ Irregular gallbladder wall thickening, infiltration into liver<br />
○ Hypoechoic b<strong>and</strong>s or nodules in thick gallbladder wall on<br />
ultrasound<br />
○ Coexisting gall stones<br />
○ May be indistinguishable from GB carcinoma<br />
(Left) Transverse ultrasound of<br />
the gallbladder shows 2 small<br />
nondependent cholesterol<br />
polyps st as an incidental<br />
finding in a patient with<br />
lymphoma ſt. (Right)<br />
Longitudinal decubitus<br />
ultrasound of the gallbladder<br />
shows a dependent nonmobile<br />
echogenic polyp in the<br />
gallbladder neck ſt. The lack<br />
of mobility distinguishes this<br />
from a nonshadowing<br />
calculus, although some<br />
calculi are adherent.<br />
Gallbladder Cholesterol Polyp<br />
Gallbladder Cholesterol Polyp<br />
908
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