R e s i d e n t s S e c t i o n S t r u c t u r e d R ev i ew A r t i c l e

OConnor and Maher

Imaging of Cholecystitis

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Residents Section
Structured Review Article

Residents

inRadiology
Owen J. OConnor 1
Michael M. Maher 1,2
OConnor OJ, Maher MM

Keywords: cholecystitis, CT of abdomen, gallbladder

disease, ultrasound of abdomen
DOI:10.2214/AJR.10.4340
Received January 26, 2010; accepted after revision
May 22, 2010.
1
Department of Radiology, Cork University Hospital,
University College Cork, Wilton, Cork, Ireland. Address
correspondence to M. M. Maher (m.maher@ucc.ie).
2
Department of Radiology, Mercy University Hospital,
Cork, Ireland.

CME
This article is available for CME credit.
See www.arrs.org for more information.
WEB
This is a Web exclusive article.
AJR 2011; 196:W367W374
0361803X/11/1964W367
American Roentgen Ray Society

Imaging of Cholecystitis
Educational Objectives
1. Acute cholecystitis is one of the most common reasons for hospital admission with
acute abdominal pain.
2. Approximately 9095% of acute cholecystitis is related to gallstones, with 510% of
cases due to acalculous disease.
3. Ultrasound is more useful than CT and
MRI for the initial evaluation of acute biliary disease.
4. CT is arguably the best technique for imaging
of complicated gallbladder disease, particularly for direct imaging of emphysematous
cholecystitis, gallstone ileus, and confirmation of suspected gallbladder perforation.
5. Cholescintigraphy may complement ultrasound and CT for the diagnosis of acalculous cholecystitis and for differentiating
acute from chronic cholecystitis.
Gallbladder disease is a common cause of
upper abdominal pain, and acute cholecystitis is one of the most common reasons for
hospital admission in patients with acute abdominal pain [1]. Imaging plays an important role in the management of cholecystitis because gallbladder disease usually has a
good prognosis provided diagnosis and management occur expeditiously [2] (Table 1).
Disease Epidemiology and
Pathophysiology
An estimated 25 million Americans have
cholelithiasis. In 80%, the cholelithiasis is
primarily composed of cholesterol, with pigments, calcium bilirubinate, and calcium carbonate accounting for most of the remainder
[3, 4]. Acute cholecystitis is due to gallstone
impaction in the gallbladder neck or cystic
duct in 9095% of cases, with bile stasis, gallbladder ischemia, cystic duct obstruction, and
systemic infection responsible for most cases
of acalculous cholecystitis [1, 5]. Acalculous
cholecystitis can be difficult to diagnose because it is most often seen in critically ill pa-

tients, such as those in the ICU, in whom clinical signs may be masked and imaging signs
are less specific compared with the ambulant
population [6]. Forty percent of patients with
acute cholecystitis develop complications [7]
(Table 1), including emphysematous cholecystitis, which is seen more commonly in men
and diabetic patients, with calculi present in
less than 50% of cases [8]. Recurrent acute
cholecystitis or biliary colic usually associated with gallstones leads to low-grade inflammation and fibrosis of the gallbladder wall,
which characterizes chronic cholecystitis [8].
Imaging Strategies
Conventional radiography is of limited value in the setting of gallbladder disease because
only 1520% of gallstones are visible on a
radiograph of the abdomen and little information about complicated gallbladder disease can be obtained using conventional radiography [3] (Fig. 1). Ultrasound is preferred
for gallstone detection and is more useful in
the initial evaluation of acute biliary disease
than CT because ultrasound helps to triage patients who require further imaging from those
who do not [9]. One of the most important
advantages of ultrasound over other imaging
techniques in the investigation of acute cholecystitis is the ability to assess for a sonographic
Murphy sign, which is a reliable indicator of
acute cholecystitis with a sensitivity of 92%
[10]. Eliciting a positive sonographic Murphy sign can help distinguish acute acalculous cholecystitis from a distended gallbladder
caused by prolonged fasting, but it is important to remember that this sign may be masked
by altered mental status or medications [11].
Ultrasound and CT are less accurate for diagnosing acalculous cholecystitis compared
with calculus cholecystitis. An assessment of
cystic duct patency with cholescintigraphy is
probably the best strategy for imaging suspected acalculous cholecystitis [8].

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OConnor and Maher

TABLE 1: Diseases of the Gallbladder [21, 24]

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Type

Disease

Calculous disease

Gallstones, gallstone ileus, Mirizzi syndrome

Infection

Empyema (suppurative cholecystitis), emphysematous cholecystitis, gangrenous cholecystitis, mucocele

Inflammation

Cholecystitis (acute, complicated, chronic, xanthogranulomatous), porcelain gallbladder

Neoplasia

Benign neoplasms (adenomyomatosis, lipoma, fibroma, myxoma, granular cell tumor, leiomyoma, hemangioma, neurofibroma),
hyperplastic cholecystosis, gallbladder carcinoma, metastases (pancreatic, gastric, renal, ovarian, melanoma)

Iatrogenic disease

Postcholecystectomy (abscess, hematoma, bile leak, cystic duct remnant pathology)

Trauma

Perforation, torsion

Fig. 1Radiography, ultrasound, and CT images in three patients with gallstones.

A, Radiograph shows abdominal multiple calcific densities conforming to gallbladder shape in right upper quadrant in 57-year-old man.
B, Ultrasound of abdomen in 42-year-old woman shows multiple echogenic foci (arrow), which cast well-defined acoustic shadow in gallbladder, consistent with
gallstones.
C, Axial CT image in 64-year-old man shows multiple hyperattenuating calculi (arrow) in gallbladder.

Ultrasound and cholescintigraphy share

similar sensitivities for the detection of acute
calculus cholecystitis; however, they may also
complement one another when there is diagnostic uncertainty [4]. Visualization of gallbladder wall thickening in the presence of
gallstones using ultrasound has a positive
predictive value of 95% for the diagnosis of
acute cholecystitis [10]. Unfortunately, thickening of the gallbladder wall in the absence
of cholecystitis may be observed in systemic
conditions, such as liver, renal, and heart failure, possibly due to elevated portal and systemic venous pressures [12]. Cholescintigraphy using hepatobiliary iminodiacetic acid is
of particular benefit in cases in which the diagnosis is uncertain and for the differentiation
of acute from chronic cholecystitis [6] (Fig.
2). Cholescintigraphy with morphine administration may be used to increase gallbladder
filling by enhancing sphincter of Oddi tone.
This technique helps reduce the incidence of
false-positive studies [8]. Chronic cholecystitis may be diagnosed by calculating the percentage of isotope excreted (ejection fraction)
from the gallbladder after cholecystokinin or
fatty meal administration [13] (Fig. 3).
Although CT is inferior to ultrasound for
the detection of gallstones in the gallbladder,
it is the best technique for imaging compli-

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Fig. 2Normal
hepatobiliary
iminodiacetic acid scan
in 64-year-old man
shows prompt hepatic
accumulation of isotope
with excretion into biliary
tree observed within
10 minutes of injection.
The gallbladder (arrow)
is visualized within 20
minutes of injection
and shows progressive
accumulation of isotope.

cated gallbladder disease such as emphysematous cholecystitis, a gallbladder disease in

which a positive sonographic Murphy sign
is observed in less than one third of patients
[9, 14]. Oral cholecystography is seldom performed but is as sensitive for gallstone detection as ultrasound, better quantifies gallstone
numbers, and confirms cystic duct patency
by showing gallbladder contractility [15].
Imaging Appearances
At ultrasound, gallstones are normally
seen as mobile echogenic foci casting posterior acoustic shadows, and sometimes a wall-

echo-shadow sign is observed if the gallbladder is filled with gallstones [4, 16] (Fig. 1).
Gallstones may appear hyper-, iso-, or hypoattenuating at CT [8] (Fig. 1). Nitrogen
gas accumulation within gallstone fissures is
sometimes observed in a star-shaped pattern
on CT, termed the Mercedes-Benz sign
[4]. Ultrasonic imaging signs of acute cholecystitis include gallbladder wall thickening
(> 3 mm), wall edema, gallbladder distention
(> 40 mm), positive sonographic Murphy
sign, and pericholecystic and perihepatic (C
sign) fluid [2, 17] (Fig. 4). On cholescintigraphy, biliary excretion of radioisotope within

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Imaging of Cholecystitis
Fig. 3Normal
hepatobiliary
iminodiacetic acid
scan after fatty meal
in 57-year-old woman
shows progressive
excretion of isotope from
gallbladder (arrow) after
fatty meal ingestion.
Ejection fraction of 44%
was observed.

Fig. 4Ultrasound and CT in 72-year-old man with acute acalculous cholecystitis.

A, Ultrasound image of upper abdomen shows gallbladder wall thickening (straight arrow), sludge (arrowhead),
and pericholecystic fluid (curved arrow) with no gallstones identified.
B, Portal venous phase CT image of abdomen also shows gallbladder wall thickening (arrow) and
pericholecystic fluid (curved arrow).

Fig. 5
Cholescintigraphy in
72-year-old woman
with acute cholecystitis
shows prompt biliary
excretion of isotope
after injection,
with subsequent
accumulation of isotope
in small bowel (arrow).
The gallbladder is not
observed.

10 minutes of injection in the absence of isotope accumulation in the gallbladder within 1 hour is typical of acute cholecystitis [8]
(Fig. 5). It is recommended that imaging be
continued for a further 3 hours to exclude delayed filling, or alternatively morphine can
be administered at 1 hour and imaging continued for a further 30 minutes [13].
Acute cholecystitis on CT is associated with pericholecystic inflammatory fat
stranding; hypo- or hyperattenuating gallstones; and edematous hyperattenuation of
the hepatic gallbladder fossa, termed transient hepatic attenuation difference [2]. CT
is particularly useful for evaluating the many
complications of acute cholecystitis, such as
emphysematous cholecystitis, gangrenous
cholecystitis, hemorrhage, and gallstone ileus. Emphysematous cholecystitis is typically diagnosed on CT by the presence of intraluminal or intramural gas, which may be
mistaken for calculi or porcelain gallbladder
on ultrasound (hyperechoic reverberation artifact) or MRI (signal void) [7, 18] (Figs. 6
and 7). Gangrenous cholecystitis is suggested on CT by the presence of intraluminal
membranes, gas within the gallbladder wall
or lumen, irregular or discontinuous mural
enhancement, or a wall defect [8] (Fig. 8).
Alternating mural hypo- and hyperattenuating foci are said to be specific signs of necrosis on CT [19]. Ischemic necrosis of the
gallbladder causing gangrene produces ulceration, hemorrhage, or microabscess formation of the gallbladder wall, which result
in asymmetry and focal intramural hyperintensity on fat-suppressed T2-weighted MRI
[1]. On ultrasound, gallbladder wall striation
or intraluminal membranes are observed.
Gangrenous cholecystitis leads to mural necrosis, which is the most common cause of
perforation, and because both necrosis and
perforation share many clinical signs in
common, a high index of suspicion is prudent because early operative intervention is
fundamental to a good outcome [7].
IV contrast administration at MRI and CT
may help diagnose gangrenous cholecystitis,
which lacks enhancement and gallbladder
perforation, seen as a gallbladder wall defect
[7] (Fig. 9). The three subtypes of gallbladder perforation that are described include
localized perforation, cholecystoenteric fistula, and free intraperitoneal spillage that
can later result in a loculated biloma [2, 20]
(Fig. 10). The most common site of perforation is the gallbladder fundus [7] (Fig. 11).
Perforation is often difficult to diagnose, but

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OConnor and Maher

Fig. 6Conventional radiography, ultrasound, CT,
and MRI in 87-year-old man with emphysematous
cholecystitis.
A, Conventional radiograph shows dilated air-filled
gallbladder with air in wall (arrow).
B, Ultrasound image shows echogenic material
(arrow) in region of gallbladder, but this cannot be
definitively seen to lie within gallbladder wall or
lumen.
C, CT image shows air in gallbladder (straight arrow),
pericholecystic fat stranding (arrowhead), and
gallbladder wall thickening (curved arrow), consistent
with emphysematous cholecystitis.
D, T2-weighted fat-saturated MR image shows
reduced signal intensity within lumen of gallbladder,
suggesting sludge or pus. In addition, signal void is
noted anteriorly within lumen of gallbladder (arrow),
suggestive of air, and collection is noted outside
gallbladder (arrowhead).

Fig. 7Ultrasound and conventional radiography in

64-year-old man with porcelain gallbladder.
A, Ultrasound image shows hyperechoic focal
area (arrow) in gallbladder bed, initially thought to
represent gallstones in gallbladder.
B, Kidneys and upper bladder examination
performed after ultrasound shows concentric mural
calcification of gallbladder (arrow), consistent with
porcelain gallbladder.

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the detection of an extraluminal gallstone or

gallbladder collapse in the presence of peri
cholecystic fluid or abscess are helpful signs
[20]. Close inspection of the circumference
of the gallbladder wall for focal defects is
also vital in patients with suspected perforated gallbladder [7]. CT is more sensitive than
ultrasound for the detection of perforation;
nevertheless, a mural defect is observed in
only 70% of cases [21]. ERCP or MRI may
be beneficial in such circumstances and for
the assessment of suspected bile leak after
cholecystectomy (Fig. 12).
CT is arguably the best method for imaging gallstone ileus. The imaging signs of
pneumobilia, an ectopic gallstone, and bowel obstruction constitute the Rigler triad [2]
(Fig. 13). Additional features of gallstone
ileus include gallbladder collapse and a fistulous connection between the gallbladder and
the duodenum, small bowel, or colon [4]. A
central focus of low density within a calculus due to the presence of cholesterol may

Fig. 8CT image in 54-year-old man with gangrenous

cholecystitis shows pericholecystic fat stranding,
no enhancement of gallbladder wall, and gas in wall
(arrow) and lumen of gallbladder.

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Imaging of Cholecystitis

Fig. 9Ultrasound, MRCP, CT, and ERCP in 87-yearold man before and after gallbladder perforation.
A, Ultrasound shows thickened gallbladder wall
(arrow) and large gallstone in gallbladder neck,
consistent with acute cholecystitis.
B, MRCP image shows large gallstone in gallbladder
and small distal common bile duct stone (arrow).
C, ERCP image obtained after A and B but before D
shows large filling defect in gallbladder (arrow) and
extravasation of contrast (arrowhead), consistent
with perforation.
D, Ultrasound obtained after A and B shows
heterogeneous mass due to localized gallbladder
perforation (arrow) with no discernible gallbladder
wall.
E, CT image confirms presence of complex collection
in gallbladder fossa secondary to perforation (arrow).

Fig. 10CT image in 80-year-old woman with

cholecystoenteric fistula due to cholecystitis shows
collapsed gallbladder with defect in opening into
duodenum (arrow). Biliary stent (arrowhead) is present.

Fig. 11Ultrasound and CT in 79-year-old man with gallbladder perforation.

A, Ultrasound shows thickening of gallbladder wall, consistent with cholecystitis.
B, CT image shows defect in wall of gallbladder at its fundus, with localized biloma (arrowhead).

help identify an ectopic gallstone located

within the small bowel lumen [4]. CT may
also identify the level of obstruction, which
is most commonly observed in the terminal
ileum [2]. A gallstone also may compress
and obstruct the common bile duct when impacted in the cystic duct or infundibulum of
the gallbladder. This phenomenon is termed
Mirizzi syndrome [4] (Fig. 14).

Cholecystitis, trauma including iatrogenesis, coagulopathy, and malignancy are

known causes of gallbladder hemorrhage [2].
CT depicts hyperattenuating fluid and ultrasound depicts echogenic or heterogeneous
fluid, but MRI may be more specific than
both [2] (Fig. 15). Intracellular methemoglobin in hemobilia has high and low signal on
T1- and T2-weighted MRI, respectively [18].

Extracellular methemoglobin may be high on

both T1- and T2-weighted MRI. Gradientecho sequences are particularly sensitive for
the presence of hemorrhage [22]. Pus within
the gallbladder (empyema) resembles sludge
on ultrasound, CT, and MRI, with material (echogenic, hyperattenuating, low signal)
in the dependent portion of the gallbladder
[7]. Findings therefore need to be correlated

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OConnor and Maher

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Fig. 12CT, ultrasound, and ERCP in 71-year-old man with bile leak after cholecystectomy.
A, CT image shows collection of hypoattenuating fluid and air (arrow) in gallbladder fossa. Patient had signs of
infection, and this was initially believed to be infected postoperative collection.
B, Ultrasound image shows echogenic collection (arrow) in subhepatic space. Drainage catheter was inserted
at this time.
C, ERCP image shows percutaneous drain (arrowhead) and contrast extravasation (arrow) consistent with bile
leak.

Fig. 13Conventional radiography and CT in 82-yearold woman with gallstone ileus.

A, Radiograph of abdomen shows multiple dilated
small-bowel loops (arrow) in mid abdomen.
B, CT image confirms small-bowel dilatation (arrow)
to transition point, at which location gallstone was
located. Gallstone contains gas which displays
Mercedes-Benz sign (arrowhead).

A
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Fig. 14ERCP and coronal maximum-intensityprojection CT images in 77-year-old woman with

jaundice secondary to Mirizzi syndrome.
A, ERCP image shows smooth extrinsic compression
of proximal common bile duct (arrow) with stenosis of
lumen and intrahepatic biliary dilatation.
B, CT image shows common bile duct obstruction
was due to impacted gallstone in neck of gallbladder
(arrowhead). Stent has been inserted into common
bile duct (black arrow) and portal vein is also seen
(white arrow).

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Imaging of Cholecystitis

Fig. 15Ultrasound and CT in 60-year-old woman with hepatitis C and gallbladder hematoma after liver biopsy.
A, Unenhanced CT image obtained 8 days after liver biopsy shows hyperattenuating lesion (arrow) in gallbladder, suggesting hematoma.
B, Ultrasound image obtained 9 days after liver biopsy shows echogenic hemorrhage (arrow) in gallbladder.
C, Ultrasound image obtained 5 weeks after liver biopsy shows complete resolution.

Fig. 16Cholescintigraphy in 80-year-old woman with chronic cholecystitis.

A, After conventional cholescintigraphy, 0.01 g/kg cholecystokinin was infused over 3-minute period and imaging of gallbladder (arrow) was performed for 30 minutes
after injection.
B, Ejection fraction was calculated by subtracting maximum from minimum counts and dividing by maximum number of counts within region of interest drawn around
gallbladder. Ejection fraction in this case was 6%, consistent with chronic cholecystitis.

with clinical history and physical examination (diabetes or atherosclerosis are important in the context of empyema, emphysematous cholecystitis, or hemorrhage) and
ultrasound-guided aspiration or prophylactic
placement of a cholecystostomy catheter may
be necessary for confirmation.
Chronic cholecystitis is characterized by
the presence of gallbladder wall thickening
in the presence of gallstones with fibrosis of
the wall, which disrupts normal motility and
may result in a contracted appearance [8].
The ultrasound and CT features of chronic cholecystitis can be nonspecific. Cholescintigraphy is useful for diagnosing chronic cholecystitis and for the differentiation
of acute from chronic cholecystitis. Signs of
chronic cholecystitis on cholescintigraphy
include delayed gallbladder isotope accumu-

Fig. 17Ultrasound image in 61-year-old woman with

adenomyomatosis shows thickening of gallbladder
wall with multiple echogenic intramural foci with
associated ring-down artifact consistent with
adenomyomatosis. Sludge (arrowhead) is also noted
in dependent portion of gallbladder.

lation, irregular gallbladder filling, or photopenic areas and septations. A gallbladder

ejection fraction of less than 35% after the
administration of cholecystokinin indicates
the presence of chronic calculus or chronic
acalculous cholecystitis [23] (Fig. 16).

Porcelain gallbladder is an uncommon manifestation of chronic cholecystitis (Fig. 7). It is

best seen on CT as plaques or punctate foci of
mural calcification. Prophylactic cholecystectomy may be performed in these circumstances
because of the association between porcelain

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OConnor and Maher

gallbladder and gallbladder carcinoma, which
is estimated to be between 11% and 33% [21].
Chronic cholecystitis may mimic gallbladder
carcinoma, particularly in the setting of xanthogranulomatous cholecystitis, which may
cause asymmetric thickening of the gallbladder wall, a gallbladder mass, or an infiltrative
mass in the absence of metastases [21]. This diagnosis is seldom made preoperatively, but the
presence of hypoattenuating mural nodules is
a useful sign [8]. Diffuse subserosal hypoattenuation due to adipose proliferation may be
observed on CT in cholesterolosis and adenomyomatosis, which are benign hyperplastic
noninflammatory gallbladder conditions. The
intramural diverticula that occur in adenomyomatosis usually produce gallbladder wall
thickening on CT [6]. Adenomyomatosis on ultrasound is suggested by the presence of immobile echogenic cholesterol crystals with a comet tail due to ring-down artifact and a thickened
gallbladder wall [12] (Fig. 17).
Conclusion
Ultrasound, CT, MRI, cholescintigraphy,
and ERCP play complementary roles in the
imaging of gallbladder disease. Acute gallbladder disease is best imaged first with ultrasound and later, where necessary, with
CT, MRI, and cholescintigraphy particularly
for complicated disease.
References
1. Gore RM, Yaghmai V, Newmark GM, Berlin JW,
Miller FH. Imaging benign and malignant disease
of the gallbladder. Radiol Clin North Am 2002;
40:13071323
2. Smith EA, Dillman JR, Elsayes KM, Menias CO,
Bude RO. Cross-sectional imaging of acute and
chronic gallbladder inflammatory disease. AJR

2009; 192:188196
3. Zeman RK. Cholelithiasis and cholecystitis. In:
Gore RM, Levine MS, Laufer I, eds. Textbook of
gastrointestinal radiology. Philadelphia, PA, PA:
Saunders, 1994:16361674
4. Bortoff GA, Chen MY, Ott DJ, Wolfman NT,
Routh WD. Gallbladder stones: imaging and intervention. RadioGraphics 2000; 20:751766
5. Barie PS, Fischer E. Acute acalculous cholecystitis. J Am Coll Surg 1995; 180:232244
6. Gibson RN. The biliary system. In: Adam A,
Dixon AK, eds. Grainger and Allisons diagnostic radiology, 5th ed. Philadelphia, PA: Elsevier,
2008: 763788
7. Watanabe Y, Nagayama M, Okumura A, et al. MR
imaging of acute biliary disorders. RadioGraphics 2007; 27:477495
8. Bennett GL. Cholelithiasis, cholecystitis, choledocholithiasis, and hyperplastic cholecystoses. In:
Gore RM, Levine MS, eds. Textbook of gastrointestinal radiology, 3rd ed. Philadelphia, PA: Elsevier, 2008:14111456
9. Harvey RT, Miller WT Jr. Acute biliary disease:
initial CT and follow-up US versus initial US and
follow-up CT. Radiology 1999; 213:831836
10. Ralls PW, Colletti PM, Lapin SA, et al. Real-time
sonography in suspected acute cholecystitis: prospective evaluation of primary and secondary
signs. Radiology 1985; 155:767771
11. Shuman WP, Rogers JV, Rudd TG, Mack LA,
Plumley T, Larson EB. Low sensitivity of sonography and cholescintigraphy in acalculous cholecystitis. AJR 1984; 142:531534
12. van Breda Vriesman AC, Engelbrecht MR, Smithuis RH, Puylaert JB. Diffuse gallbladder wall
thickening: differential diagnosis. AJR 2007;
188:495501
13. Krishnamurthy S, Krishnamurthy GT. Cholecystokinin and morphine pharmacological intervention during 99mTc-HIDA cholescintigraphy: a ra-

tional approach. Semin Nucl Med 1996; 26:1624

14. Simeone JF, Brink JA, Mueller PR, et al. The
sonographic diagnosis of acute gangrenous cholecystitis: importance of the Murphy sign. AJR
1989; 152:289290
15. Maglinte DD, Torres WE, Laufer I. Oral cholecystography in contemporary gallstone imaging:
a review. Radiology 1991; 178:4958
16. MacDonald FR, Cooperberg PL, Cohen MM. The
WES triad: a specific sonographic sign of gallstones in the contracted gallbladder. Gastrointest
Radiol 1981; 6:3941
17. Adusumilli S, Siegelman ES. MR imaging of the
gallbladder. Magn Reson Imaging Clin N Am 2002;
10:165184
18. Grayson DE, Abbott RM, Levy AD, Sherman
PM. Emphysematous infections of the abdomen
and pelvis: a pictorial review. RadioGraphics
2002; 22:543561
19. Teefey SA, Baron RL, Radke HM, Bigler SA.
Gangrenous cholecystitis: new observations on
sonography. J Ultrasound Med 1991; 134:191194
20. Bennett GL, Balthazar EJ. Ultrasound and CT
evaluation of emergent gallbladder pathology. Radiol Clin North Am 2003; 41:12031216
21. Haaga JR, Herbener TE. The gallbladder and biliary tract. In: Haaga JR, Lanzieri CF, Gilkeson
RC, eds, CT and MR imaging of the whole body,
4th ed. St. Louis, MO: Mosby, 2003:13411394
22. Altun E, Semelka RC, Elias J Jr, et al. Acute
cholecystitis: MR findings and differentiation
from chronic cholecystitis. Radiology 2007;
244:174183
23. Chamarthy M, Freeman LM. Hepatobiliary scan
findings in chronic cholecystitis. Clin Nucl Med
2010; 35:244251
24. Federle MP, Jeffery RB. Biliary system. In: Federle MP, Jeffery RB, Desser TS, Anne VS, Eraso
A, eds. Diagnostic imaging: abdomen. Salt Lake
City, UT: Amirsys, 2008:161

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abdominal pain. Emergency Radiology 21, 615-624. [CrossRef]
5. Pumersha Naidoo, Bhugwan Singh. 2014. Current radiological strategies for the assessment of right lower quadrant abdominal
pain. South African Journal of Radiology 18. . [CrossRef]
6. Sungmin Woo, Jeong Min Lee, Jeong Hee Yoon, Ijin Joo, Se Hyung Kim, Jae Young Lee, Jung Hwan Yoon, Yoon Jun Kim,
Joon Koo Han, Byung Ihn Choi. 2013. Small- and Medium-sized Hepatocellular Carcinomas: Monopolar Radiofrequency
Ablation with a Multiple-Electrode Switching SystemMid-term Results. Radiology 268, 589-600. [CrossRef]
7. Antonio Pinto, Alfonso Reginelli, Lucio Cagini, Francesco Coppolino, Antonio Stabile Ianora, Renata Bracale, Melchiore
Giganti, Luigia Romano. 2013. Accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis: review of the
literature. Critical Ultrasound Journal 5, S11. [CrossRef]
8. Massimo Tonolini, Anna Ravelli, Chiara Villa, Roberto Bianco. 2012. Urgent MRI with MR cholangiopancreatography
(MRCP) of acute cholecystitis and related complications: diagnostic role and spectrum of imaging findings. Emergency Radiology
19, 341-348. [CrossRef]
9. Mark Tulchinsky, Harvey A. Ziessman, Alan H. Maurer. 2012. Current Standard Technique for Cholecystokinin
Cholescintigraphy. American Journal of Roentgenology 198:1, W93-W93. [Citation] [Full Text] [PDF] [PDF Plus]
10. Owen J. OConnor, Michael M. Maher. 2012. Reply. American Journal of Roentgenology 198:1, W94-W94. [Citation] [Full
Text] [PDF] [PDF Plus]