ULTRASOUND CORNER

GALLBLADDER WALL THICKNESS

KATHYA. SPAULDING,
DVM
Veterinaly Radiology & Ultrasound, 34:270-272, 1993

ening of the wall of the body and fundus of the gallbladder.

T he canine gallbladder is a pek-shaped vesicle that lies
in a fossa between the quadrate liver lobe medially and
the right lateral lobe laterally. It is divided into the fundus,
When peritoneal fluid is present in the gallbladder fossa, the
inner hyperechoic wall is the true wall of the gallbladder,
body and neck. The rounded cranial end is the fundus, the the hypoechoictanechoic region is the accumulated peri-
middle portion is the body and the slender, caudally taper- cholecystic fluid and the outer hyperechoic area is the se-
ing extremity is the neck. The neck communicates with the rosal, capsular surface of the liver. Free fluid accumulation
cystic duct.’ in the gallbladder fossa results in focal collection in the
The normal gallbladder wall is sonographically visible as perineckkystic duct area with focal loss of the uniform
a thin echogenic line. The wall typically measures about 2 “wall” thickness (Fig. 3). Imaging of the neck region of
mm-3 mm in thickness (Fig. 1). Wall thickness varies with the gall bladder will often assist in differentiating true wall
transducer type and placement or angulation of the sound thickness from pericholecystic fluid accumulation. Posi-
beam relative to the organ insonated. Wall measurement tional changes of the animal will result in redistribution of
will be most accurate if the region of the gall bladder wall this fluid and assist in differentiating free pericholecystic
measured is the near wall and the wall is oriented perpen- fluid from a thickened gallbladder wall. Examining other
dicular to the sound beam.’ Image degradation due to re- areas of the abdomen, especially adjacent to the urinary
verberation or slice thickness artifacts may require measure- bladder, will often confirm the presence of peritoneal effu-
ment of the far wall. Measurement of the lateral aspect of sion. However, edematous changes in the wall and perito-
the wall of a curved or round structure is to be avoided as it neal effusion may be present concomitantly as a result of
will appear thicker than normal due to refraction and slice similar pathophysiologic mechanisms.
thickness artifacts.374
Following cholecystic calculi: the most frequent gallblad-
der abnormality detected by sonography in people is diffuse
wall thickening. Wall thickening is diagnosed when the
wall is thicker than 3-3.5 Wall thickening typi-
cally appears as a hypoechoic region between two
echogenic lines (Fig. 2). Gallbladder wall thickening is usu-
ally categorized as diffuse or focal. Focal wall changes are
less common and are usually caused by specific underlying
gallbladder lesions such as a tumor, polyp, cyst, or hyper-
plasia. Diffuse thickening result in a uniform enlargement
of the wall.
Peritoneal fluid localization in the gallbladder fossa may
be erroneously diagnosed as gallbladder wall thickening.
True thickness of the wall is present when there is unifor-
mity in thickness with the outer wall of the neck of the
gallbladder confluent with the wall of the cystic duct. When
free peritoneal fluid accumulates within the fossa surround- FIG. 1. Dorsal-plane image through the left liver with the normal gall
ing the gallbladder, there may be an apparent uniform thick- bladder in the far field: The appearance of the hepatic vein and portal vein
is due to color Doppler insonation (1). The near and far walls of the gall
bladder appear as thin hyperechoic lines (2). Measurements are best made
from this surface or the far wall when reverberation distorts the wall
thickness. There is a reverberation artifact extending from the near wall of
Department of Anatomy, Physiological Sciences and Radiology, Col- the gall bladder into the lumen of the gall bladder (3). Measurement of wall
lege of Veterinary Medicine, North Carolina State University, 4700 Hills- thickness at the periphery of the gallbladder image will be inaccurate
borough St., Raleigh, North Carolina 27606. because of refraction and slice thickness artifacts.

270
VOL.34, No. 4 GALLBLADDER
WALLTHICKNESS
FIG. 2. The gall bladder wall is uniformly thickened from edema (1).
There is hyperechoic inspisated bile present in the dependent portion of the
gall bladder (2). The bile contents are echogenic (3). The dog had severe
pulmonary thromboembolism following heartworm adulticide therapy, and
also had disseminated intravascular coagulopathy and right heart failure.
The stomach wall was also edematous.
Although initially described as highly specific for chole-
cystitis, diffuse gallbladder wall thickening is now recog-
nized as neither sensitive nor specific for an inflammatory
process. In people, approximately 50% to 75% of patients
with acute cholecystitis have diffusely thickened a gallblad-
FIG. 3. The gall bladder wall is artificially thickened due to peritoneal
effusion (1). Fluid accumulated in the region adjacent to the neck of the
gall bladder (2) may be used to distinguish between wall thickening and
peritoneal effusion in the gall bladder fossa.
27 1
der wall, whereas fewer than 25% of patients with chronic
cholecystitis have this
Cholecystitis is inflammation of the gall bladder wall
accompanied by infection. In acute cholecystitis, there is
diffuse hyper-reflective wall thickening, hazy wall delinea-
tion, and gallbladder distention. The hypoechoic layer rep-
resents subserosal edema and necrosis. The inner, hyperre-
flective contour coincides with the lamina propria and mus-
cularis, with thickness and irregularity of the outer contour
likely related to the degree of edema and cellular infiltration
in the subserosa and adjacent liver parenchyma (Fig. 4).
This “halo” has been reported in 26% of people diagnosed
with acute cholecystitis. Additionally, there may be a hy-
poreflective layer, which is continuous or interrupted within
the hyperreflective, thickened gall bladder. There is in-
creased vascular permeability with edema, extravasation of
blood in the wall, and polymorphonuclear and mononuclear
infiltration. In severe cholecystitis, the mucous membrane
is completely destroyed. The pathologic changes depend on
the severity and chronicity of the process. The gall bladder
lumen may be filled with cloudy or turbid bile containing
FIG. 4. The wall of the gallbladder in this dog with cholecystitis is
markedly thickened (5 mm) (1). The lumenal contents are echogenic.
Severe and diffuse gall bladder intramural edema and hemorrhage and
hepatic necrosis were c o n f i i e d on histopathologic examination. A toxic
etiology was suspected.
272 SPAULDING
fibrin and purulent material.2’5”’8 Biliary sludge appears
sonographically as mobile echogenic material within the
lumen; this sludge can appear similar to exudate. A cursory
appraisal of viscosity of the bile can be determined by re-
positioning the animal and noting the mobility of the
echogenic material. Causes for strands of echogenic mate-
rial are nonspecific but more likely to be associated with
inflammation.
Other possible causes of wall thickness reported in people
include; hypoproteinemia, right-sided cardiac failure, he-
patic dysfunction associated with hypoalbuminemia, hepa-
titis, some chemotherapeutic drugs, ascites, renal disease,
sepsis, systemic venous hypertension, multiple myeloma
and physiologic thickening resulting from partial wall con-
tracture. Increased gallbladder wall thickness has also been
reported with adenomyomatosis, gallbladder tumors, peri-
cholecystic abscess, and possibly varices resulting from
portal In one series reported in people,
all patients with ascites had gallbladder wall thi~kening.~
With ascites, the plasma colloid oncotic pressure and portal
venous pressure may influence wall thickness. Hypopro-
teinemic stages probably produce this by a decreased intra-
vascular osmotic effect as occurs in the intestinal wall. With
congestive heart failure, there is increased systemic and
portal venous engorgement, which may produce edema of
the wall. The thickened gall bladder wall may potentially be
secondary to focal obstruction of the gall bladder lymphatic
drainage by malignant lymphsma in portal lymph nodes.
Obstruction of the lymphatic drainage of an organ results in
increased interstitial fluid and thickening of the tissues. In
chronic cholecystitis there may be a thickened wall and a
small contracted lumen (Fig. 5). A unifying pathophysio-
logic mechanism may be related to a decreased intravascu-
lar osmotic pressure and elevated portal venous pressure.6
In dogs, reported causes for gall bladder wall thickening
include cystic mucosal hyperplasia, infectious canine hep-
atitis, and biliary tumors. Other possible causes, in addition
to those reported in people, include pancreatitis, chronic
bile duct obstruction with subsequent formation of fibrous
tissue, renal failure and overhydration. 14,15
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1. Evans HE, Christensen GC: Miller’s Anatomy of the Dog, 2nd
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1993
FIG. 5. The wall of this partially contracted gall bladder is thickened (4
mm) (1). This was due to chronic cholecystitis.
There are several factors that affect the pathogenesis of
cholecystitis. These include chemical irritation by concen-
trated bile, bacterial infection, and pancreatic reflux. Stone
obstruction of the cystic duct is implicated in 80-90% of
human patients with acute cholecystitis.276Choleliths in
dogs are relatively uncommon and when present, are often
not clinically significant. Bile stasis and bacteria may be of
primary importance in the manifestation of clinical signs in
dogs and cats with choleliths because abnormal cholesterol
metabolism, which is a major factor in the formation of gall
bladder caIculi in people, is not considered a major factor in
stone formation in dogs and cat^.'^''^
Thickening of the gall bladder wall may be associated
with multipIe etiologies. There may also be pseudothicken-
ing of the wall due to peritoneal effusion. When apparent
thickening of the wall of the gall bladder is observed, it is
important to determine actual wall thickening and to seek
the underlying cause. Clinical evidence of gallbladder dis-
ease may not be present. The diagnosis of cholecystitis
solely on the basis of wall thickening should be made with
caution.
9. Handler SJ. Ultrasound of gallbladder wall thickening and its rela-
tion to cholecystitis. AJR 1979;132:581-585.
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