945

Sonography of the Gallbladder:

Significance of Striated (Layered)
Thickening of the Gallbladder Wall

Sharlene A. Teefey1 Sonographic identification of thickening ofthe gallbladder wall that consists of multiple
Richard L. Baron1 striations (alternate hypoechoic and hyperechoic layers) has been considered strong
Stephen A. Bigler2 evidence of the presence of acute cholecystitis. We studied 27 patients in whom
sonograms showed striated thickening of the gallbladder wall to determine the diagnos-
American Journal of Roentgenology 1991.156:945-947.

tic significance of this finding. Stnations were classified as focal or diffuse. Sonograms
were correlated with pathologic findings in 16 patients and with clinical diagnoses and
laboratory findings in 11. Patients were categorized as having cholecystitis with or
without gangrene or edema of the gallbladder wall unrelated to gallbladder disease.
Striated thickening of the gallbladder wall was due to cholecystitis in 10 patients, and
all 10 had gangrenous changes at surgery or at pathologic examination. Striations were
focal in eight of these patients and diffuse in two. Striated thickening
of the gallbladder
wall was due to edema of the wall unrelated to gallbladder disease in 17 patients.
Causes included congestive heart failure (n = 4), renal failure (n = 5), liver disease
(hepatic failure (n = 1], hepatitis [n = 6]), ascites (n = 2), hypoalbuminemia (n = 3),
pancreatitis (n = 1), blockage of the lymphatic/venous drainage of the gallbladder (n =
2), and prominent Rokftansky-Aschoff sinuses (n = 1). More than one abnormality was
present in five patients. Striations were focal in 11 of these patients and diffuse in six.
The sonographic finding of striated gallbladder wall thickening is no more specific for
cholecystitis than the observation of gallbladder wall thickening by itself, and it may
occur in a variety of diseases. However, in the clinical setting of acute cholecystitis, the
presence of striations suggests gangrenous changes in the gallbladder. The extent of
the striations (focal or diffuse) is not useful in predicting the cause of the striated
gallbladder wall thickening.

AJR 156:945-947, May 1991

Several reports indicate that sonographic evidence of gallbladder wall thickening

may be due to a variety of disorders not directly related to gallbladder disease [1-
7]. However, a recent report suggests that gallbladder wall thickening consisting
of multiple striations (alternate hyperechoic and hypoechoic layers) is indicative of
the presence of acute cholecystitis [8]. We studied 27 patients with striated
thickening of the gallbladder wall on sonograms to determine the diagnostic
significance and specificity of this finding.

Received September 21, 1990; accepted after

revision December 26, 1990. Materials and Methods
Department of Radiology, University of Wash-
We reviewed the reports of 7300 nonobstetric sonograms obtained at Seattle Veterans
ington School of Medicine, Seattle, WA 98105.
Address reprint requests to S. A. Teefey, Seattle Affairs Medical Center between July 1986 and February 1990. Sonograms of 128 patients in
Veterans Affairs Medical Center, 1660 5. Colum- whom the sonograms were reported to show gallbladder wall thickening were reviewed. In
bian Way. Seattle, WA 98108. 27 of these, sonography showed gallbladder wall thickening with a striated appearance.
2 Department of Pathology, University of Wash- Striations were defined as sonolucent bands separated by echogenic zones forming layers in
ington School of Medicine, Seattle, WA 98105. the gallbladder wall. All 27 patients were men between 30 and 81 years old.
0361 -803X/91/1 565-0945 Clinical records were reviewed to determine the presence of abnormalities known to cause
© American Roentgen Ray Society gallbladder wall thickening (congestive heart failure, renal failure, hepatitis, cirrhosis, ascites,
 946 TEEFEY ET AL. AJR:156, May 1991

Fig. 1.-75-year-old man with pancreatitis

who underwent cholecystectomy. sonogram
shows diffuse striations as multiple hypoechoic
layers (arrowheads) separated by echogenic
zones. Histologic examination of gallbladder
showed a well-preserved mucosa and no evi-
dence of wall inflammation; however, serosa
was thickened and had appearance of granula-
tion tissue. Strlatlons were thought to be due to
reactive changes in serosa from pancreatitis.

Fig. 2.-41-year-old man who underwent

cholecystectomy. Histologic examination of gall-
bladder revealed gangrenous changes. Sono-
gram shows focal, striated thickening of gall-
bladder wall adjacent to hepatic surface.

and hypoalbuminemia). If the patient had a cholecystectomy, chole- months to 2 years supported these clinical findings and
cystostomy, or autopsy, the pathologic findings in the gallbladder showed no evidence of interval development of biliary tract
were determined. Histologic slides of the gallbladder were reviewed. disease. The sixth patient died of unrelated causes 1 1 days
Gangrenous cholecystitis was diagnosed if there was coagulative after the sonographic study, and an autopsy was not per-
necrosis in addition to severe, acute, or chronic inflammation.
formed.
All sonograms were performed in real time by using an ATL
Striated thickening of the gallbladder wall was due to
American Journal of Roentgenology 1991.156:945-947.

(Advanced Technology Laboratories, Bellevue, WA) Ultramark 8 scan-

ner(n = 22)or a Diasonic DRF 400 scanner(Diasonics Corp., Milpitas, hepatitis in six patients. Four had clinical and laboratory
CA)(n= 5). evidence of alcoholic hepatitis and two of viral hepatitis
Static images from the sonographic studies were reviewed for the (Figs. 3A and 3B). Follow-up of patients from 4 months to 2
presence of gallbladder wall thickening greater than 3 mm and for years supported these clinical findings and showed no evi-
the presence of striations in the wall (multiple hypoechoic layers dence of interval development of biliary tract disease.
separated by echogenic zones) (Fig. 1) [8]. A determination was Pathologic correlation was available in five patients with
made of whether the striations were focal or diffuse. edema of the gallbladder wall unrelated to gallbladder disease.
Sonographic findings were correlated with pathologic findings after In three of these cases, findings at autopsy did not reveal the
cholecystectomy, cholecystostomy, or autopsy in 1 6 of the 27 pa-
gallbladder wall abnormalities noted at sonography. Clinical
tients. In the other 1 1 patients, sonographic findings were correlated
diagnoses in these three cases included renal and hepatic
with the clinical diagnoses and laboratory findings. Patients were
placed into one of two groups: (1) those with cholecystitis with or failure, hepatic venocclusive disease, and cholangiocarcinoma
without gangrene or (2) those with edema of the gallbladder wall remote from the gallbladder. Autopsy performed three to 16
unrelated to gallbladder disease. days after the sonograms revealed a normal gallbladder in
these three cases. In the two remaining cases, clinical, oper-
ative, and pathologic correlation suggested unusual causes
of striated thickening of the gallbladder wall. The first patient
Results
had pancreatitis (Fig. 1). The second patient with chronic renal
Striated thickening of the gallbladder wall was due to failure and hypoalbuminemia (1 .6 g/dl) underwent cholecys-
cholecystitis in 10 patients, nine of whom underwent chole- tectomy for suspected cholecystitis. At surgery, the gallblad-
cystectomy. Histologic examination of the gallbladder re- der wall showed moderate edema. Histologic examination of
vealed gangrenous changes in all nine patients. Acute inflam- the gallbladder showed preservation of the mucosa, promi-
mation was present in seven of these patients and chronic nent Rokitansky-Aschoff sinuses, a thickened muscularis, and
inflammation in two. The tenth patient had operative place- no evidence of inflammatory changes.
ment of a cholecystostomy tube at which time gangrenous Striated thickening of the gallbladder wall was focal in 11
changes were observed. No patient had cholecystitis without of the patients with edema of the gallbladder wall unrelated
gangrenous changes. Striated thickening of the gallbladder to gallbladder disease and diffuse in six. Gallbladder wall
wall was focal (Fig. 2) in eight of the patients with gangrenous thickening ranged from 4 to 14 mm.
cholecystitis and diffuse in two. Gallbladder wall thickening
ranged from 5 to 1 2 mm.
Discussion
Striated thickening of the gallbladder wall was due to edema
of the wall unrelated to gallbladder disease in 1 7 patients. Although it is well known that the finding of gallbladder wall
Review of the clinical records of six of these patients showed thickening on sonography may be due to many causes, both
multisystem disease including congestive heart failure (n = biliary and nonbiliary, a recent report suggests that sono-
4), renal failure (n = 3), ascites (n = 2), and hypoalbuminemia graphic evidence of striations or layering of the gallbladder
(n = 2). More than one abnormality was present in three wall is a sign of acute cholecystitis [8]. Our study shows that
patients. Pathologic examination of the gallbladder in one of this finding is suggestive of acute gangrenous cholecystitis
these patients with profound hypoalbuminemia showed no (1 0 of 1 0 patients with cholecystitis). However, in patients
evidence of cholecystitis. Follow-up of four patients from 2 without clinical evidence of acute cholecystitis, striated thick-
 AJR:156, May 1991 SONOGRAPHY OF GALLBLADDER 947

Fig. 3.-35-year-old man with viral hepatitis,

type A.
A, Sonogram shows marked, diffuse gallblad-
der wall strlations. Gallbladder lumen (arrow) Is
compressed by thickened gallbladder wall.
B, Sonogram shows resolution of wall thick-
ening I month later.

ening of the gallbladder wall may be seen in a variety of nous cholecystitis, coagulation necrosis often involves all
abnormalities, including congestive heart failure, renal failure, layers of the gallbladder wall. Perhaps in patients with gan-
liver disease (hepatic failure, hepatitis), ascites, hypoalbumi- grenous cholecystitis it is the full thickness involvement of the
nemia, pancreatitis, blockage of the lymphatic and/or venous wall that produces the striations observed at sonography.
drainage of the gallbladder, and prominent Rokitansky-As- Ukewise, in patients with edema of the gallbladder wall un-
choff sinuses. The extent of the striations (focal or diffuse) related to gallbladder disease, it may be the relatively even
was not helpful in determining the cause of the striated distribution of the fluid throughout the layers of the wall that
gallbladder wall thickening because focal striations were pres- produces the striations observed at sonography. Further
American Journal of Roentgenology 1991.156:945-947.

ent in the majority of patients with gangrenous cholecystitis studies with close sonographic-histologic correlation are nec-
(eight of 1 0 patients) and edema of the gallbladder wall essary to confirm these speculations.
unrelated to gallbladder disease (1 1 of 1 7 patients). In conclusion, the sonographic finding of gallbladder wall
Although there was no sonographic-pathologic correlation thickening with striations may be due to several pathologic
in 1 1 cases, follow-up from 2 months to 2 years showed no processes unrelated to primary disease of the gallbladder.
evidence of primary gallbladder disease in 1 0 of these cases. However, in the clinical setting of acute cholecystitis, the
The 1 1 th patient died of unrelated causes 1 1 days after the presence of striations suggests that the patient has acute
sonogram. An autopsy was not performed, but there was no gangrenous cholecystitis.
clinical evidence of biliary tract disease. Although the diag-
nosis of acute cholecystitis may have been overlooked in
ACKNOWLEDGMENTS
these cases, our patients had no evidence for this and had
other diseases known to cause gallbladder wall thickening. In The authors acknowledge Cheryl Colacurcio for her sonographic
three other cases, sonographic gallbladder wall abnormalities expertise and John D. Harley for editorial assistance.
were not evident at autopsy. We believe that this discrepancy
was due to the time interval between the sonogram and
REFERENCES
autopsy (3-16 days) and the use of alcohol to prepare the
histologic specimen. Alcohol, a dehydrating agent, is known 1 . Shlaer WJ, Leopold GR, Scheible FW. Sonography of the thickened
to remove fluid from edematous organs. We can only specu- gallbladder wall: a non-specific finding. AJR 1981;136:337-339
2. RaIls PW, Quinn MF, Juttner HV, Halls JM, Boswell WD. Gallbladder
late that the striations were due to hepatic and renal failure in
wall thickening: patients without intrinsic gallbladder disease. AJR
one of these cases, and due to blockage of the venous and/ 1981;137:65-68
or lymphatic drainage of the gallbladder in the other two 3. Wegener M, Borsch G, Schneider J, Wedmann B, Winter R, Zacharias J.
patients with hepatic venocclusive disease and cholangiocar- Gallbladder wall thickening: a frequent finding in various nonbiliary disor-
cinoma. In two additional cases, pathologic correlation sug- ders-a prospective ultrasonographic study. JCU 1987; 15:307-312
4. Fiske CE, Laing FC, Brown TW. Uflrasonographic evidence of gall-
gested unusual causes of striated thickening of the gallblad-
bladder wall thickening in association with hypoalbuminemia. Radiology
der wall. We again had to speculate that the striations were 1980;135: 71 3-716
due to reactive changes in the serosa in the patient with 5. Laudanna AA, Ferreyra NP, Cern GG, Bettarello A. Thickening of the
pancreatitis, and due to wall edema, Rokitansky-Aschoff Si- gallbladder wall in alcoholic hepatitis verified by ultrasonographic exami-
nation. Scand J Gastroenterol 1987;22 :521-524
nuses, and a thickened muscularis in the patient with renal
6. Maresca G, DeGaetano AM, Mirk P, Cauda R, Federico G, Colagrande C.
failure and hypoalbuminemia. Sonographic patterns of the gallbladder in acute viral hepatitis. JCU
We cannot readily explain why edema alone causes striated 1984;12:141-146
thickening of the gallbladder wall in patients without evidence 7. Juttner HV, RaIls PW, Quinn MF, Jenney JM. Thickening of the gall-
bladder wall in acute hepatitis: ultrasound demonstration. Radiology
of primary gallbladder disease, whereas in acute cholecystitis,
1982;142:465-466
the appearance correlates with gangrene. In uncomplicated
8. Cohan RH, Mahony BS, Bowie JD, Cooper C, Baker ME, Illescas FF.
acute cholecystitis, inflammation is limited primarily to the Striated intraluminal gallbladder lucencies on US studies: predictors of
submucosal layer of the gallbladder wall, whereas in gangre- acute cholecystitis. Radiology 1987; 164:31-35