Imaging Pearls ❯ Gallbladder ❯ Inflammatory Disease
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- “Gallstone formation plays an important role in gallbladder disease pathophysiology and affects 10% to 15% of the adult population. Although up to 80% of patients with gallstones will never be symptomatic or require treatment, complications related to gallstones result in a significant health care burden of approximately $6.2 billion annually, an increase of more than 20% over the past 3 decades. Despite the indolent course of typical gallstone disease, patients at high risk for biliary complications may require intervention.”
Gallbladder Imaging Interpretation Pearls and Pitfalls
Sergio P. Klimkowski et al.
Radiol Clin N Am - (2022) https://doi.org/10.1016/j.rcl.2022.05.002 - "Despite the indolent course of typical gallstone disease, patients at high risk for biliary complications may require intervention. These groups include patients with large gallstones greater than 3 cm or gallbladders packed with gallstones, patients with sickle cell disease,solid organ transplant recipients, and/or high-risk patients undergoing abdominal surgery for other reasons (eg, morbidly obese patients undergoing bariatric surgery).”
Gallbladder Imaging Interpretation Pearls and Pitfalls
Sergio P. Klimkowski et al.
Radiol Clin N Am - (2022) https://doi.org/10.1016/j.rcl.2022.05.002 - "Gallbladder disease is a common clinical problem in both emergent and nonemergent settings and includes both malignant and benign etiologies. Imaging evaluation of the right upper quadrant plays a key role in establishing the correct diagnosis. Clinical history, physical examination, and laboratory values are important in the accurate imaging assessment of the right upper quadrant. Significant overlap in imaging features of both benign and malignant etiologies can pose diagnostic dilemmas. Additionally, inherent limitations of ultrasound and cross-sectional techniques may lead to diagnostic pitfalls preventing accurate diagnosis. Knowledge of these pitfalls and their solutions help in the accurate assessment of the gallbladder.”
Gallbladder Imaging Interpretation Pearls and Pitfalls
Sergio P. Klimkowski et al.
Radiol Clin N Am - (2022) https://doi.org/10.1016/j.rcl.2022.05.002
- “CT is noninferior to ultrasound in both ruling in and ruling out the diagnosis of cholecystitis in adult patients undergoing emergency evaluation of right upper quadrant pain and offers the advantage of depicting acute nongallbladder abnormalities.”
Role of Ultrasound and CT in the Workup of Right Upper Quadrant Pain in Adults in the Emergency Department: A Retrospective Review of More Than 2800 Cases
Kevin D. Hiatt et al.
AJR 2020; 214:1305–1310 - “In the sub- group analysis, ultrasound showed an acute nongallbladder abnormality that was missed at a preceding CT examination in only 1 of 238 cases (0.4%). CT showed an acute nongallbladder abnormality missed at a preceding ultrasound examination in 103 of 322 cases (32%).”
Role of Ultrasound and CT in the Workup of Right Upper Quadrant Pain in Adults in the Emergency Department: A Retrospective Review of More Than 2800 Cases
Kevin D. Hiatt et al.
AJR 2020; 214:1305–1310 - “Furthermore, CT more commonly showed a nongallbladder cause of right upper quadrant pain (25% of CT versus 0.4% of US studies). This finding supports recent research indicating a high diagnostic yield of CT regardless of the abdominal quadrant of presenting patient pain.”
Role of Ultrasound and CT in the Workup of Right Upper Quadrant Pain in Adults in the Emergency Department: A Retrospective Review of More Than 2800 Cases
Kevin D. Hiatt et al.
AJR 2020; 214:1305–1310 - “Although US continues to have an impor-tant role in the workup of right upper quadrant pain, we advocate for CT as a primary imaging modality for both the diagnosis and exclusion of cholecystitis, such that a follow- up US examination is considered unnecessary and should be discouraged. We also conclude that CT provides added benefit in being able to depict additional pathologic conditions as a source of right upper quadrant pain.”
Role of Ultrasound and CT in the Workup of Right Upper Quadrant Pain in Adults in the Emergency Department: A Retrospective Review of More Than 2800 Cases
Kevin D. Hiatt et al.
AJR 2020; 214:1305–1310 
Role of Ultrasound and CT in the Workup of Right Upper Quadrant Pain in Adults in the Emergency Department: A Retrospective Review of More Than 2800 Cases
Kevin D. Hiatt et al.
AJR 2020; 214:1305–1310
- OBJECTIVE. In 2013, a multidisciplinary group at our Veterans Administration hospital collaborated to improve the diagnosis and treatment of patients with acute cholecystitis (AC) at our facility. Our role in this project was to evaluate the diagnostic accuracies of ultrasound (US) and CT.
CONCLUSION. CT was significantly more sensitive for diagnosing AC than US. CT and US are complementary, and the other modality should be considered if there is high clinical suspicion for AC and the results of the first examination are negative
Comparing the Diagnostic Accuracy of Ultrasound and CT in Evaluating Acute Cholecystitis
Wertz JR et al.
AJR 2018; 211:W92–W97 - RESULTS. The sensitivity of CT for detecting AC was significantly greater than that of US: 85% versus 68% (p = 0.043), respectively; however, the negative predictive values of CT and US did not differ significantly: 90% versus 77% (p = 0.24–0.26). Because there were no false-positives, the specificity and positive predictive values for both modalities were 100%. Among the 42 patients who underwent CT and US, both modalities were positive for AC in 25 patients, CT was positive and US was negative in 10 patients, and US was positive and CT was negative in two patients; in five patients, both US and CT were negative.
Comparing the Diagnostic Accuracy of Ultrasound and CT in Evaluating Acute Cholecystitis
Wertz JR et al.
AJR 2018; 211:W92–W97 - "More than 90% of patients in surgical wards are seen for one or more of the following conditions: acute appendicitis, AC, small-bowel obstruction, urinary colic, perforated peptic ulcer, acute pancreatitis, acute diverticular disease, and nonspecific non-surgical abdominal pain."
Comparing the Diagnostic Accuracy of Ultrasound and CT in Evaluating Acute Cholecystitis
Wertz JR et al.
AJR 2018; 211:W92–W97 - "US had a sensitivity of 68% (38/56) and negative predictive value (NPV) of 77% (60/78). CT had a sensitivity of 85% (41/48) and an NPV of 90% (60/67). There were no false-positives in either group, yielding specificity and positive predictive values (PPVs) of 100%."
Comparing the Diagnostic Accuracy of Ultrasound and CT in Evaluating Acute Cholecystitis
Wertz JR et al.
AJR 2018; 211:W92–W97 - "However, US is still our first test of choice if AC is suspected clinically, whereas CT is performed when the clinical picture is unclear. US and CT are complementary: If the initial test is negative and there is clinical suspicion of AC or if the ini- tial examination is equivocal, the other examination should be performed. In our practice if both studies are negative for AC and clinical suspicion is high for AC, hepatoiminodiacetic acid scanning is performed.
Comparing the Diagnostic Accuracy of Ultrasound and CT in Evaluating Acute Cholecystitis
Wertz JR et al.
AJR 2018; 211:W92–W97 - "The sensitivity of US (68%) and CT (85%) for AC were not as good as sensitivities reported in prior studies: 81% for US and 94% for CT. CT at our institution was statistically significantly better for the diagnosis of AC than US, most likely because of an unclear clinical picture, the patient population, and a high proportion of poor-quality US examinations."
Comparing the Diagnostic Accuracy of Ultrasound and CT in Evaluating Acute Cholecystitis
Wertz JR et al.
AJR 2018; 211:W92–W97
- “ The absence of gallbladder wall enhancement (associated with the presence of gangrenous acute cholecystitis) and the presence of a gallstone in the gallbladder infundibulum are associated with conversion from laparoscopic to open cholecystectomy.”
Acute Cholecystitis: Preoperative CT Can Help the Surgeon Consider Conversion from Laparoscopic to Open Cholecystectomy
Fuks D et al.
Radiology 2012; 263:129-138 - “ Local or widespread absence of gallbladder wall enhancement at CT was associated with the intraoperative presence of gangrenous acute cholecystitis (sensitivity,73%; negative predictive value, 93%).”
Acute Cholecystitis: Preoperative CT Can Help the Surgeon Consider Conversion from Laparoscopic to Open Cholecystectomy
Fuks D et al.
Radiology 2012; 263:129-138 - “ Knowledge of these risk factors may improve patient safety by minimizing time to conversion and helping identify patients in whom immediate open cholecystectomy is indicated.”
Acute Cholecystitis: Preoperative CT Can Help the Surgeon Consider Conversion from Laparoscopic to Open Cholecystectomy
Fuks D et al.
Radiology 2012; 263:129-138
- Adenomyomatosis
- Benign, acquired hyperplastic cholecystosis
- Often have cholelithiasis
- Usually asymptomatic; infrequently causes pain
- Pathologically involves the mucosa and muscularis propria - Adenomyomatosis: CT
1. Thickened wall
2. Invaginated proliferated surface epithelium ~ diverticuli
- not 100% specific (can be seen in cancer)
3. CT rosary sign:
- Mucosal enhancement within diverticuli
- Surrounded by hypodense hypertrophic muscularis - Xanthogranulomatous Cholecystitis
1. Chronic cholecystitis, usually w/ cholelithiasis
2. Mimics gallbladder cancer radiographically
3. Pathology
- Mucosal ulceration
- Destructive acute and chronic inflammation in presence of lipid-laden macrophages
- Numerous histiocytes, polymorphonucleocytes - XGC: CT
- Cholelithiasis
- Wall thickening >3 mm
- Focal or diffuse wall thickening
- Intramural hypodense nodules
- Hypodense mural band: most specific
- Gallbladder mass - Complicated Acute Cholecystitis
- Perforation leading to ascites or abscess/collection
- Gangrenous cholecystitis
- Emphysematous cholecystitis
- Hemorrhagic cholecystitis - Gangrenous Cholecystitis
- Severe acute cholecystitis resulting in transmural necrosis
- Wall of the gallbladder replaced by acute inflammation with extensive background necrosis. - Gangrenous Cholecystitis: US
1. gallstones
2. wall thickening, can be striated
3. diffuse intraluminal echogenicities
- exudate and debris
4. intraluminal membranes
- sloughed mucosa
5. absent sonographic Murphy sign in 2/3 - Gangrenous Cholecystitis: CT
- intraluminal membranes
- irregular or absent wall
- absence of mural enhancement
- gas in wall or lumen
- abscess - Emphysematous Cholecystitis
- Patients with vascular insufficiency at higher risk (i.e. diabetics)
- Vascular compromise devitalizes gallbladder wall
- Superinfection with gas producing organisms
- US: reverberation artifact within acoustic shadowing
- CT: Gas in gallbladder lumen, wall or pericholecystic fat
- No communication with bowel to account for gas - Hemorrhagic Cholecystitis
Predisposing factors:
- stones usually present
- trauma
- anticoagulation
- renal failure
- cirrhosis
- underlying mass - Hemorrhagic Cholecystitis
1. Presentation
- RUQ symptoms
- +/- hemobilia or GI bleeding
2. High mortality rate
3. Complications
- CBD obstruction
- hemoperitoneum - Advanced Post-processing
1. IV contrast enhanced studies
2. Biliary tree fluid density against enhanced liver
3. Display using orientation best suited for evaluation (coronal, sagittal, oblique)
- 2D MPRs
- Minimum intensity projection
- Volume rendering and VRCP - Cholangitis
1. Infectious
- Obstruction due to stone or tumor
- Cholecystitis
- AIDs
2. Inflammatory
- Primary sclerosing cholangitis - Primary Sclerosing Cholangitis
- Chronic cholestatic liver disease
- Fibroobliterative sclerosis of bile ducts
- Eventually leads biliary cirrhosis
- Associated with inflammatory bowel disease - Primary Sclerosing Cholangitis
- Multiple strictures
- Saccular dilatation
- Pruning
- Irregularity of extrahepatic common duct
- Extrahepatic ductal stenosis
- Diverticulum-like outpouchings - Benign Distal CBD Stenosis
- Stenosis of sphincter of oddi
- Cholelithiasis
- Pancreatitis
- AIDS cholangitis
- Complications of Acute Cholecystitis
- Gangrenous cholecystitis
- Emphysematous cholecystitis
- Pericholecystic fluid
- Vascular complications - Gallbladder Pathology
- Distended if greater than 5 cm in short axis and greater than 8 cm in length
- Wall thickening is greater than 4mm - Acute Cholecystitis: CT Findings
- Gallbladder distention
- Wall thickening
- Mucosal hyperenhancement
- Pericholecystic fat stranding or fluid gallstones (65-75% of cases visualized) - "In patients with acute cholecystitis, portal vein thrombosis is not uncommon.Patterns of transient increased hepatic attenuation were found to vary, depending on the presence or absence of portal vein thrombosis."
Relationship Between Various Patterns of Transient Increased Hepatic Attenuation on CT and Portal Vein Thrombosis Related to Acute Cholecystitis
Choi SH et al.
AJR 2004; 183:437-442 - Emphysematous Cholecystitis
- Caused by secondary infection of the gallbladder wall with gas forming organisms
- Affected patients are most commonly diabetic, male and 40-60 years of age
- Can be precursor to gangrene, perforation, or abscess formation - Gangrenous Cholecystitis
- Most common complication in up to 38% of untreated cases
- Perforation can occur in up to 10% of untreated cases
- Defects in gallbladder mucosa or sloughed intraluminal membranes should suggest gangrene of the gallbladde - "Reactive hyperemia resulting in increased enhancement of the hepatic parenchyma of the gallbladder fossa may also be present (CT rim sign)."
CT Findings of Acute Cholecystitis and Its Complications
Shakespear JS et al.
AJR 2010;194:1523-1529 - "Complications of acute cholecystitis have a characteristic CT appearance and include necrosis, perforation, abscess formation, intraluminal hemorrhage, and wall emphysema."
CT Findings of Acute Cholecystitis and Its Complications
Shakespear JS et al.
AJR 2010;194:1523-1529 - Acute Cholecystitis: CT Findings
- Gallstones
- Thickening of the gallbladder wall
- Pericholecystic fluid
- Blurring of the gallbladder/liver interface
- Stranding of the pericholecystic fat - Emphysematous Cholecystitis: CT Findings and Facts
- Most commonly seen in diabetics
- Usually due to gas forming organisms like Clostridium perfringens, E. coli and Klebsiella organisms
- 15% mortality
- Air is seen in gallbladder lumen or wall
- Surgery is open removal of the gallbladder - Mirizzi’s Syndrome
Obstruction of the extrahepatic bile duct by a stone impacted within the cystic duct and subsequent extrinsic compression or inflammation