ULTRASONOGRAPHIC EVALUATION OF GALLBLADDER WALL

THICKNESS IN CATS
M. HITTMAIR,
KATHARINA DR. MED.VET, HANNA DR. MED.VET.,
D. VIELGRADER,
GERHARD LOUPAL,DR.MED.VET.

Ultrasonography of the gallbladder and biliary tract was performed on 42 cats: 22 clinically healthy cats
(group A) and 20 cats with hepatobiliary disease and post mortem confirmation of gallbladder abnor-
malities (group B). The gallbladder wall was visible in 9 of 22 cats in group A and all 20 cats in group
B. Additional gallbladder findings in group B included shape anomalies, biliary tract obstruction, wall
thickening, polyps, neoplasia, and biliary sludge. Ultrasonographic evaluation of abdominal organs
identified pancreatic disease as the predominant pathological cause of extrahepatic biliary obstruction.
Hepatic parenchymal involvement was noted with inflammation and thickening of the gallbladder wall.
Histologically, gallbladder walls were characterized by mucous gland hyperplasia, inflammation, infil-
tration, edema, epithelial detachment, and/or neoplasia. Ultrasonographic and histologic gallbladder
wall measurements of 20 cats in group B agreed within 0.4 mm and all cats with a gallbladder wall
thickness 21.0 mm had histopathologic abnormalities of the wall. Serum biochemical analysis revealed
elevations of one or more parameters in all cats of group B, but was non-specific for a gallbladder lesion.
The results of this study indicate that a visible, echogenic gallbladder wall can be considered a normal
variant and is not always associated with hepatobiliary disease. Ultrasonography is accurate in mea-
suring gallbladder wall thickness. Wall thickness greater than l mm is accurate in predicting galiblad-
der disease in cats, while a thickness less than 1 mm cannot rule out mild or chronic inflammation.
Veterinary Radiology & Ultrasound, Vol. 42, No. 2, 2001, p p 149-155.

Key words: gallbladder wall, biliary tract, cat, ultrasonography.

Introduction sludge are seen. These lesions have been reported to be

present in cats and dogs without signs of hepatobiliary dis-

T HE HEPATIC PARENCHYMA is often involved secondary to

diseases of the gallbladder and/or biliary tract.I4 Clini-
cal signs of gallbladder or hepatobiliary disease in cats in-
clude non-specific symptoms such as lethargy, weight loss,
vomiting, diarrhea, as well as more specific clinical findings
such as icterus and hepat~megaly.~ Cats with hepatobiliary
disorders often have vague clinical signs until the disease
becomes progressive.6
Anatomy of the gallbladder and biliary tract is respon-
sible for involvement in various nonbiliary diseases. The
intrahepatic small bile ducts are joined into one or more
hepatic ducts, which flow together with the tortuous cystic
duct to form the common bile duct. The common bile duct
and the pancreatic duct empty into the duodenum, 3 cm
from the pylorus, at the duodenal ~ a p i l l a . ~
Ultrasonographic abnormalities of the gallbladder in cats
often appear as incidental findings during routine examina-
tions. Most commonly, thickening of the gallbladder wall or
ease.'-''
Diffuse gallbladder wall thickening in humans is consid-
ered a non-specific finding and may be associated with in-
trinsic gallbladder diseases such as cholecystitis or caused
by systemic disorders including hypoalbuminemia, right-
sided heart failure, portal hypertension, hepatitis, renal dis-
ease, and ascites.''," Gallbladder wall thickness up to 3.0
mm in humans is reported to be n0rma1.l~Normal wall
measurements in dogs are 2.0-3.0 mm.14 In dogs, gallblad-
der wall thickening is reported with cystic mucosal hyper-
plasia, cholecystitis, infectious canine hepatitis, biliary tu-
mors, pancreatitis, chronic bile duct obstruction, renal fail-
ure, ~verhydration,'~ and gallbladder mucocele.'"'6 There
are no reports on gallbladder wall thickness in cats.
The purpose of this study was to assess the gallbladder
wall in clinically healthy cats using ultrasonography and to
compare these findings to those in cats with hepatobiliary
disease.

From the Radiology Clinic (Hittmair, Vielgrader) and Institute for Pa-
thology and Forensic Veterinary Medicine (Loupal), University of Veteri-
nary Medicine, Vienna, Austria.
Address correspondence and reprint requests to Dr. Katharina Hittmair,
Radiology Clinic, University of Veterinary Medicine, Veteriniirplatz I ,
A- I2 1 0 Vienna, Austria.
Received March 27, 2000; accepted for publication August 21, 2000.
Materials and Methods
Forty-two cats were included in this study and divided
into 2 groups. Group A consisted of 22 clinically healthy
cats from a breeding colony, 1 I males and 11 females, with
an average age of 9 yrs (range 8 to 10 yrs). No abnormalities

149
150 HITTMAIR
ET AL. 200 I

were found during physical examination and no previous

history of hepatobiliary disease was known. Group B con-
sisted of 20 cats, 1 1 males and 9 females, with a mean age
of 8.6 yrs (range 0.1 to 15.3 yrs), referred to the Radiology
Clinic for an ultrasound examination. These cats had sus-
pected hepatobiliary disease based on clinical evaluation.
The cats in group B were included in this study if there was
post mortem confirmation of gallbladder abnormalities and
wall measurements.
Blood samples were collected from both group A and B
for serum biochemical analysis and evaluated for serum
alkaline phosphatase (ALP), aspartate aminotransferase
(AST), alanine aminotransferase (AST), y-glutamyl trans-
ferase (GGT), glutamate-dehydrogenase (GLDH), total bil-
irubin, bile acids, triglycerides, and cholesterol.
Abdominal ultrasonography was performed on cats fasted FIG. 1. Normal gallbladder in a cat. The gallbladder contents are an-
echoic, the gallbladder wall is visible. The echoes near the gallbladder neck
for a minimum of 12 hours (group A) or approximately 6 are reverberation artifacts.
hours (group B). The cats did not require sedation for the
examination. They were placed in right lateral recumbency
Twenty cats in group B had signs of hepatobiliary and/or
to view the cranial and left abdominal cavity, followed by
gastrointestinal disease. Clinical signs were anorexia ( I 5 /
left lateral recumbency to examine the opposite side. All
20), vomiting (17/20), diarrhea (10/20), abdominal pain (8/
cats were scanned using a 5 to 8 MHz curved-may trans-
20), icterus (1 1/20), or a combination of these signs. Ultra-
ducer.*
sonographic gallbladder findings in these cats included cho-
The liver and gallbladder were examined in longitudinal
lestasis (6), shape anomalies ( 3 ) , diffuse wall thickening
and transverse planes. The gallbladder and bile ducts (when
(1 l), polyps (l), neoplasia (l), and sludge (8).
visible) were evaluated for size, wall thickness, and con-
In 6 of 20 cats, signs of biliary tract obstruction were
tents. Gallbladder wall thickness was determined ultrasono-
identified ultrasonographically. The gallbladder appeared
graphically in all 42 cats using measurement calipers. Any
distended (Fig. 2), the gallbladder wall was thickened and
non-visible gallbladder wall was rated as 0 mm. Gallbladder
echogenic, and dilatation of the common bile duct was
waH thickness was measured on 3 different images in lon-
present. Gallbladder sludge was detected in 4 cats. Intrahe-
gitudinal views at the body and fundus and mean values
patic bile ducts were dilated in 2 of the 6 cats and appeared
were calculated. Abnormal ultrasonographic findings of ab-
more tortuous than blood vessels. Ultrasonographic wall
dominal organs were recorded.
thickness ranged from 0.6-1.6 mm. In 3 of the 6 cats, ex-
All cats in group B were euthanized within 5 days fol-
trahepatic biliary obstruction was caused by chronic pan-
lowing the ultrasonographic examination. The gallbladder
creatitis, which was identified ultrasonographically and
was removed immediately post mortem and examined his-
topathologically (formalin fixation, paraffin embedding, HE
stain). Histopathology of the gallbladder wall included
evaluation of the degree of wall thickening, inflammation,
and mucosal lesions. Measurements of gallbladder wall
thickness were obtained on histopathology at 6 different
portions of the specimen. A mean value was calculated and
compared to the ultrasonographic measurements.

Results
In 22 healthy cats of group A, 10 cats did not have a
visible gallbladder wall (Fig. 1). Nine cats had a gallbladder
with a thin echogenic wall, ranging in thickness from 0.4-
0.9 mm. An abnormal gallbladder shape but without wall
visualization was found in 3 cats. All abdominal organs in
group A cats were sonographically normal.
FIG.2. Biliary obstruction in a cat. The gallbladder is distended, the
"ATL HD1-3000, Advanced Technology Laboratories, Bothell, Wash- gallbladder neck, cystic duct, and common bile duct are dilated. Extrahe-
ington, USA. patic biliary obstruction was caused by chronic pancreatitis.
VOL. 42, No. 2 WALL1 HICKNESS
GALLBLADDER - -
IN L A T S 151

confirmed at necropsy. In 2 of the 6 cats, a pancreatic car-

cinoma was detected ultrasonographically as a solid hypo-
echoic mass causing biliary obstruction. These tumors were
confirmed at necropsy. Histologically, there was lympho-
cytic infiltration of the gallbladder wall with edema of the
epithelium. Histopathologic gallbladder wall thickness
ranged from 0.7-1.95 mm. In 1 cat intraluminal biliary ob-
struction was caused by gallbladder neoplasia. An intramu-
ral gallbladder mass with an irregular surface, mixed
echogenicity, and measuring 14 mm was identified ultra-
sonographically (Fig. 3). Diffuse wall thickening was seen
extending into the common bile duct. Hypoechoic nodular
infiltrates were detected in the cortex of both kidneys, sug-
gestive of lymphosarcoma. Histology of the gallbladder
wall tumor, common bile duct, and kidneys confirmed lym-
phoid infiltration related to lymphosarcoma. FIG. 4. Shape anomaly of the gallbladder. The gallbladder is heart-
shaped, created by a fibrous cleft in the wall.
In 3 of the 20 cats, shape anomalies of the gallbladder
with mild wall thickening were identified ultrasonographi-
cally. The gallbladder was clefted (1/3) (Fig. 4) or bilobed gallbladder wall with edema, mucosal hyperplasia, and pu-
(2/3) (Fig, 5). Ultrasonographic wall thickness ranged from rulent inflammation, consistent with acute cholecystitis.
0.2-0.4 mm. A polyp measuring 6 mm was seen in one cat There was thickened bile and purulent material present in 3
(Fig. 6). Other abdominal findings confirmed at necropsy of 4 gallbladders. Histopathologic gallbladder wall thick-
included chronic pancreatitis (2/3), with lymph node en- ness ranged from I . 12-3.48 mm. Ultrasonographic findings
largement ( 1/3), and hepatic lipidosis (1/3). Histologic fea- of the abdomen with pathological confirmation included
tures of the gallbladder wall and polyp were non-purulent or ascites (2/4), enteritis (1/4), hyperechoic hepatic paren-
mildly purulent inflammation and mucous gland hyperpla- chyma (2/4), mesenteric lymphadenopathy (1/4), and ne-
sia. Histologic thickness ranged from 0.28-0.68 mm. phropathy (2/4).
Diffuse gallbladder wall thickening was found in 1 1 of 20 In 7 of 11 cats with diffuse gallbladder wall thickening,
cats in group B. Ultrasonographically, the gallbladder wall ultrasonographic measurements of hyperechoic walls
appeared hyperechoic (7 cats) or double-rimmed with an ranged from 0.3-1.5 mm (Figs. 8 and 9). Histologic findings
hypoechoic space between two echogenic lines (4 cats). The included mild to moderate mucous gland hyperplasia, non-
double-rimmed wall appearance in 4 cats, measuring from purulent inflammation, epithelial detachment, and wall
1 .O-3.4 mm ultrasonographically, was assessed as possible thickness of 0.43-1.52 mm. Histologic diagnosis was
cholecystitis and confirmed histologically (Fig. 7). There chronic cholecystitis. Abdominal ultrasonography allowed
was moderate leucocytic and lymphocytic infiltration of the identification of minimal amounts of sludge (l/7), diffuse
hyperechoic hepatic parenchyma (3/7), mesenteric lymph-

FIG.3. Lymphosarcoma of the gallbladder wall with intramural biliary

obstruction. A 14 mm, hypoechoic, heterogenous mass is seen at the gall-
bladder fundus. The bile contains echogenic particles. The gallbladder neck FIG.5. Bilobed gallbladder in a cat. Two gallbladder lobes are visible,
and cystic duct are dilated. joined at the cystic duct.
152 HITTMAIR
ET AL. 200 1

FIG. 6. Gallbladder wall polyp. There is a 6 mm, focal, echogenic, FIG.8. Mild gallbladder wall thickening with mild inflammation. The
intraluminal wall mass in the gallbladder fundus. Mild diffuse wall thick- gallbladder wall is hyperechoic and measures 0.8 mm.
ening is also apparent. Reverberation artifacts are seen in the near field
within the gallbladder.
is described as occasionally being- a non-specific and inci-
dental finding associated with other organ abnormalities.83y
adenopathy (1/7), and nephropathy (1/7). Ultrasonographic
The most apparent ultrasonographic gallbladder finding in 2
findings of the abdomen were unremarkable in 2 cats, ex-
groups of cats in this study was a visible, sometimes thick-
cept for gallbladder wall thickening.
ened, hyperechoic gallbladder wall. In 9 (40.9%) of 22 cats
In 11 (55%) of 20 group B cats, ultrasonographic and
of group A and all 20 cats (100%) of group B, gallbladder
histologic gallbladder wall measurements agreed within 0.4
walls were visible. Since cats of group A did not have
mm. In the other 9 (45%) cats, agreement was within 0.15
clinical signs or serum biochemistry abnormalities and were
mm.
regarded as a control group, we concluded that a visible
Serum biochemistry values were normal in all cats of
gallbladder wall is not necessarily associated with hepato-
group A and one cat in group B. All values were elevated at
biliary disease in the cat. Reasons for an ultrasonographi-
least five-fold in cats with signs of biliary obstruction. Se-
cally visible gallbladder wall in these healthy cats may be
rum bile acids were at least slightly elevated in all cats but
improved equipment or sonographer skills, previous gall-
one in group B.
bladder disease, or a normal variant. Normal ultrasono-
Discussion graphic gallbladder wall thickness of 3.0 mm in humans”
and 2.0-3.0 mm in dogs’4 is high compared to the measure-
The normal gallbladder wall has been noted to be unde-
ments made of visible walls in normal cats in this study
tectable ultrasonographically. l 7 Gallbladder wall thickening
(0.4-0.9 mm). This may be explained by more sensitive
equipment and measurements. Furthermore, there was an

FIG.7. Acute cholecystitis. There is a double-layered appearance to the

gallbladder wall with a hypoechoic layer surrounded by two hyperechoic
layers. The distance between the cursors is 3 mm; bile contents are FIG.9. Gallbladder wall thickening with chronic cholecystitis. The wall
echogenic. is uniformly hyperechoic and measures 1.5 mm.
VOL. 42, No. 2 WALLTHICKNESS
GALLBLADDER
overlap between wall measurements in both groups of cats.
Gallbladder walls of cats in group B with ultrasonographic
measurements as thin as 0.2 mm were characterized histo-
logically by mild inflammation or mucosal gland hyperpla-
sia. In these cats the gallbladder wall was considered ab-
normally thickened because of clinical signs, concurrent
abnormalities of abdominal organs and/or elevated serum
biochemistry parameters. Necropsy findings in the cats of
this study included chronic pancreatitis, pancreatic neopla-
sia, chronic liver disease, and biliary obstruction as the pre-
dominant underlying causes for gallbladder wall thickening.
Pancreatic and gastrointestinal disease, such as inflam-
mation and neoplasia, have been reported as the most com-
mon cause for extrahepatic biliary obstruction. ‘ , I x Some pa-
tients with biliary obstruction may not have a distended
gallbladder when the gallbladder is contracted due to in-
flammation. The common bile duct may remain dilated
following resolution of a previous obstruction when the
elasticity of the wall is decreased by prolonged distension or
inflammation” (Fig. 2). Thickening of the gallbladder wall
was present in all cats with biliary tract obstruction in this
study. Extrahepatic bile duct obstruction from pancreatitis
or enteritis will lead to reflux with bacteria colonizing the
biliary tract, resulting in cholecystitis.” Obstruction of lym-
phatic drainage of the gallbladder results in increased inter-
stitial fluid and thickening of the gallbladder wall. l 4
Diffuse thickening of the gallbladder wall in humans is
often associated with inflammation or cholecystitis. How-
ever, the sensitivity of these findings in distinguishing be-
tween acute and chronic cholecystitis is not high.*’ The
double rim effect of the gallbladder wall is usually seen with
acute cholecystitis and is due to edema and inflammation of
the gallbladder wall.’* The significance of this layered wall
appearance is limited in differentiating between chronic and
acute gallbladder disease, and the layers are no more spe-
cific for inflammation than the thickened wall itself.” In a
study of gallbladder wall thickening in humans, attempts
were made to correlate gallbladder wall thickness to the
degree of cholecystitis, with measurements under 3 mm
indicating mild inflammation, greater than 3 mm acute
cholecystitis, 3-6 mm with chronic disease, and greater than
6 mm gangrenous cholecystitis.” As there was an overlap
in wall measurements with chronic and acute cholecystitis,
it was found that the type of gallbladder wall pathology
could not be decided on the basis of the ultrasonographic
appearance, unless there was severe inflammation.’3 In this
study, cats of group B with ultrasonographically visible,
thick, double-rimmed gallbladder walls had acute forms of
cholecystitis, while a thinner, single-layered, hyperechoic
wall was more characteristic of chronic or mild inflamma-
tion. The ultrasonographic, double-rimmed gallbladder wall
appearance with acute cholecystitis was due in part by
edema of the epithelium. Chronic cholecystitis leads to hy-
perplasia of the mucous glands in the Irreversible
I N CATS 153
thickening due to chronic inflammation and scarring ex-
plains the hyperechoic gallbladder wall.”
Neoplasia of the gallbladder or biliary tract is reported to
be rare in the Adenomas and adenocarcinomas are
mentioned as the most probable type of tumor found in the
gallbladder wall, while other types of neoplasia affect he-
patic parenchyma.22326The ultrasonographic appearance of
biliary cystadenomas in cats has recently been described as
cystic lesions within the liver.27 The gallbladder wall mass
found in one cat had polypous proliferation of the epithe-
lium with lymphoid infiltration of the wall and common bile
duct. Ultrasonographically, the tumor had a wide base and
infiltrated the gallbladder wall. Histopathologic diagnosis
was lymphosarcoma. This type of gallbladder wall tumor
has not been described previously. Secondary to the tumor,
cholestasis was present due to mechanical intraluminal ob-
struction. Neoplastic wall lesions are difficult to differenti-
ate ultrasonographically from benign polyps. In a recent
report, ultrasonographic angiography was performed to dif-
ferentiate between various gallbladder wall lesions in hu-
mans and found to be limited in the differential diagnosis of
small polypoid-type gallbladder carcinomas and benign le-
sions2’
Ultrasonographically, gallbladder form anomalies in cats
are frequently seen as incidental findings29 and are ex-
plained by the embryologic development of the gallbladder.
The embryonic gallbladder is split longitudinally during the
solid stage, creating a partially divided organ. These paired
buds are connected to each other, while the fundic ends
remain separated. A bilobed gallbladder represents an in-
complete resolution of the solid stage with a remaining fold
or septum.3o Ultrasonographic evaluation of gallbladder
wall thickness in these cats is the same as with normal
gallbladder forms.
Ultrasonographic gallbladder wall measurements in the
cats of group B were similar to histologic measurements.
All gallbladder walls visualized ultrasonographically had
histologic features consistent with mild inflammation or
mucosal gland hyperplasia. Given the fact that gallbladder
wall thickness may vary according to the degree of disten-
sion, no significant differences were found in the measure-
ments. In humans, this has been reported previously.2133’ On
the other hand, gallbladder contractions may increase wall
width and thereby simulate pathologic thickening.” These
contractions may be responsible for a “thickened” gallblad-
der wall in some clinically healthy cats. Age-related thick-
ening of the gallbladder should also be considered. Special
care should be taken to rule out artifacts, such as refraction,
slice thickness, and reverberation, which may cause the
gallbladder wall to appear thickened ultrasonographically. l 4
Pseudothickening of the gallbladder wall is also seen with
peritoneal effusion due to the acoustic interface between the
fluid and the wall.I7
One of the problems faced when examining the gallblad-
154 HITTMAIR
ET AL.
der wall at necropsy is its rapid disintegration. Cats have
fewer mucous glands in the gallbladder wall than dogs.32
The mucous glands protect the wall from the detergent ef-
fects of bile acids.33 Autolysis of the gallbladder wall begins
immediately after death, as soon as mucous secretion stops.
These autolytic areas are histopathologically similar to wall
necrosis described with acute c h o l e ~ y s t i t i sand
~ ~ may lead
to a false diagnosis or measurement. The time lapse between
the ultrasonographic examination of the gallbladder and
subsequent histopathology was therefore kept to a mini-
mum. The cats in group B were euthanized within 5 days
following the ultrasonographic examination. Some of the
gallbladder wall measurements were repeated before eutha-
nasia. The gallbladder in euthanized cats (group B) was
removed immediately post mortem and fixated in formalin.
Autolysis or necrosis of the gallbladder wall did not appear
to be a factor in this report.
Serum biochemistry evaluations in the cats of this study
were not reliable in identifying gallbladder diseases or wall
thickening. Group A cats with a visible gallbladder wall
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