Imaging benign and malignant disease of the gallbladder
Section snippets
Clinical findings
Approximately 25 million adults in the United States have gallstones [1]. Increasing age, obesity, hyperalimentation, rapid weight reduction, ileal disease or resection, and certain ethnicity (eg, Pima Indians) are risk factors for developing gallstones [2]. Most (70–80%) gallstones in Western countries are cholesterol stones and the remainder (20–30%) are pigment stones, which occur most frequently in patients with chronic hemolytic disorders [1], [3], [4].
Approximately 80% of patients with
Gallbladder sludge
Gallbladder sludge consists of cholesterol monohydrate crystals and calcium bilirubinate granules embedded in a gel matrix of mucous glycoproteins [14]. This viscous, lithogenic bile most often develops in patients with prolonged fasting in intensive care units, trauma patients receiving total parenteral nutrition, and within 5 to 7 days of fasting in patients who have undergone gastrointestinal surgery [14].
Sludge typically has a fluctuating course and may disappear and reappear over several
Clinical findings
Acute cholecystitis is the fourth most common cause of hospital admissions for patients who present with the acute abdomen. Some 600,000 cholecystectomies are performed annually for acute cholecystitis, a number that has been steadily increasing with the aging of the population and the advent of laparoscopic cholecystectomy [15].
Acute cholecystitis usually occurs in patients with chronic biliary symptoms; it is uncommon for a previously asymptomatic patient to require an emergency
Acute acalculous cholecystitis
Acute gallbladder inflammation in the absence of stones is seen in 2% to 15% of patients undergoing cholecystectomy and accounts for 47% of cases of postoperative cholecystitis and 50% of children with acute cholecystitis. Acute acalculous cholecystitis (AAC) most commonly occurs in adults who are critically ill or have had trauma, burns, or major surgery. Other risk factors include hyperalimentation, mechanical ventilation, diabetes, sepsis, cardiac arrest, atherosclerosis, prolonged fasting,
Xanthogranulomatous cholecystitis
Xanthogranulomatous cholecystitis (XGC) is an uncommon inflammatory condition in which the gallbladder wall is thickened by the infiltration of round cells, lipid-laden histiocytes, and multiple nucleated giant cells with fibroblast proliferation in the muscularis propria. XGC is found in 0.7% to 13% of cholecystectomy specimens [50], [51], [52].
CT shows mural thickening of the gallbladder or a soft tissue mass in the gallbladder fossa. This inflammatory process may extend into the liver hilum
Porcelain gallbladder
Porcelain gallbladder is an uncommon disorder in which chronic cholecystitis produces mural calcification of the gallbladder. The term derives from the blue discoloration and brittle consistency of the gallbladder. Porcelain gallbladder, seen in 0.06% to 0.8% of cholecystectomy specimens, presents with two types of histologic calcification: (1) a broad continuous band of calcification in the muscularis, and (2) multiple punctate calcifications scattered through the mucosa and submucosa. Only
Hyperplastic cholecystoses
Hyperplastic cholecystoses encompass a diverse group of benign, nonneoplastic, noninflammatory gallbladder disorders characterized by hyperplasia of the various components of the gallbladder wall: mucosa, muscles, nerves, and glands. Adenomyomatosis and cholesterol polyps have emerged as the most significant of the hyperplastic cholecystoses, found in 5% to 25% of surgical specimens [55].
Cholesterolosis
Cholesterolosis is due to the deposition of foamy, cholesterol-laden histiocytes in the lamina propria. There are two major morphologic types of cholesterolosis: diffuse, flat, and planar type and the larger polypoid type. The first type cannot be appreciated in imaging. The second type of cholesterolosis, cholesterol polyps, occurs in 20% of cases [56].
Cholesterol polyps present sonographically as nonmobile, nonshadowing echogenic structures attached to the gallbladder wall. Cholesterol polyps
Adenomyomatosis
Adenomyomatosis (Fig. 14) is characterized by proliferation of the epithelium associated with muscular hypertrophy and mucosal–submucosal diverticula (Rokitansky-Aschoff sinuses) [55]. Adenomyomatosis manifests in three different ways: diffuse, segmental, and polypoid. The diffuse type is the least common and presents with diffuse mural thickening that can simulate other causes of diffuse thickening such as acute and chronic cholecystitis, gallbladder carcinoma, and hypoproteinemia. In the
Adenomatous polyps
Cholesterol polyps are seen sonographically in 5.3% of the population and adenomatous polyps are seen in 0.4% of cholecystectomy specimens [4]. Adenomas are the most common benign gallbladder neoplasm and only rarely degenerate into neoplasms [63]. Adenomatous polyps are usually solitary, sessile lesions ranging in size from 0.1 to 2.5 cm in diameter. Malignancy should be considered when the polyp exceeds 1 cm in diameter or when there is rapid growth of the polyp seen on follow-up sonograms
Clinical features
Carcinoma of the gallbladder is the fifth most common malignancy of the gastrointestinal tract, responsible for nearly 7000 deaths annually in the United States. It is found incidentally in 1% to 3% of cholecystectomy specimens and 0.5% to 7.4% of autopsies [66]. Risk factors for this neoplasm include gallstones (65–95%) and a history of chronic cholecystitis (40–50%), and an estimated 22% of patients with porcelain gallbladder will develop carcinoma [67]. Gallbladder carcinoma has a peak
References (85)
- et al.
Prevalence and ethnic differences in gallbladder disease in the United States
Gastroenterology
(1999) - et al.
Gallstones and biliary disease
Prim Care
(2001) - et al.
Segmental chronic cholecystitis: sonographic and clinical manifestations
Abdom Imaging
(2002) Acute cholecystitis: CT findings
Semin Ultrasound CT MR
(2000)- et al.
Gallbladder muscle dysfunction in patients with acalculous disease
Gastroenterology
(2001) - et al.
Differential diagnosis of polypoid lesions of the gallbladder by endoscopic ultrasonography
Am J Surg
(2001) - et al.
Polypoid lesions of the gallbladder: Report of 100 cases with special reference to operative indications
Surgery
(2000) - et al.
The spectrum and cost of complicated gallstone disease in California
Arch Surg
(2000) - et al.
Gallbladder stones: imaging and intervention
Radiographics
(2000) Cholelithiasis and cholecystitis
Gallstones: prevalence, diagnosis, and treatment
Isr Med Assoc J
Sonography for selecting candidates for laparoscopic cholecystectomy: a prospective study
AJR Am J Roentgenol
MR diagnosis of adenomyomatosis of the gallbladder and differentiation from gallbladder carcinoma: importance of showing Rokitansky-Aschoff sinuses
AJR Am J Roentgenol
Value of prone position in ultrasonographic diagnosis of gallstones
J Ultrasound Med
The WES sign
Radiology
Imaging of cholelithiasis: what does the surgeon need?
Abdom Imaging
Predicting gallstone composition with CT: in vivo and in vitro analysis
Radiology
Cholelithiasis: evaluation with CT
Radiology
Imaging of cholelithiasis: helical CT
Abdom Imaging
Biliary sludge
Ann Intern Med
Choledocholithiasis: role of US and endoscopic ultrasound
Abdom Imaging
Factors effecting the complication in the natural history of acute cholecystitis
Hepatogastroenterology
Gallstone pancreatitis
J Clin Gastroenterol
The diagnostic accuracy of MRCP and ultrasound compared with direct cholangiography in the detection of choledocholithiasis
Clin Radiol
Inflamed pericholecystic fat: Color Doppler flow imaging and clinical features
Radiology
Radiologic diagnosis of common bile duct stones
Abdom Imaging
Acute biliary disease: initial CT and follow-up US versus initial US and follow-up CT
Radiology
Sonography of the gallbladder: significance of striated (layered) thickening of the gallbladder wall
AJR Am J Roentgen
Further observations on the usefulness of the sonographic Murphy sign in the evaluation of suspected acute cholecystitis
J Clin Ultrasound
Sonography of acute cholecystitis: comparison of color and power Doppler sonography in detecting a hypervascularized gallbladder wall
AJR Am J Roentgen
Power Doppler ultrasound of gallbladder wall vascularization in inflammation: clinical implications
Eur Radiol
Color velocity imaging and power Doppler sonography of the gallbladder wall: a new look at sonographic diagnosis of acute cholecystitis
AJR Am J Roentgen
Blood flow in healthy gallbladder walls on color and power Doppler sonography
AJR Am J Roentgen
CT evaluation of acute cholecystitis: findings and usefulness in diagnosis
AJR Am J Roentgen
The biliary tract
Computed tomography in acute cholecystitis
Emer Radiol
The diagnosis of acute acalculous cholecystitis: a comparison of sonography, scintigraphy, and CT
AJR Am J Roentgen
Hepatobiliary scintigraphy is superior to abdominal ultrasonography in suspected acute cholecystitis
Surgery
Gallbladder disease: appearance of associated transient increased attenuation in the liver at biphasic, contrast-enhanced dynamic CT
Radiology
CT finding of transient focal increased attenuation of the liver adjacent to the gallbladder in acute cholecystitis
AJR Am J Roentgen
False positive CT diagnosis of gallstones due to thickening of the gallbladder wall
AJR Am J Roentgen
MR imaging in clinically suspected acute cholecystitis. A comparison with ultrasonography
Acta Radiol
Cited by (109)
Oncologic Emergencies in the Chest, Abdomen, and Pelvis
2023, Radiologic Clinics of North AmericaEmbryology, Anatomy, and Imaging of the Biliary Tree
2019, Surgical Clinics of North AmericaImaging in Gastroenterology
2018, Imaging in GastroenterologyWhat to Expect When They are Expecting: Magnetic Resonance Imaging of the Acute Abdomen and Pelvis in Pregnancy
2017, Current Problems in Diagnostic RadiologyRole of MSCT in the evaluation of perforated gall bladder (a retrospective study)
2016, Egyptian Journal of Radiology and Nuclear MedicineEvaluating Patients with Right Upper Quadrant Pain
2015, Radiologic Clinics of North America