GALLBLAD

DER IMAGING
 TOPIC OUTLINE

I. ANATOMY

II. IMAGING

III. DISEASES
GALLSTONE
ACUTE CHOLECYSTITIS
CHRONIC CHOLECYSTITIS
GALLBLADDER WALL THICKENING
ADENOMYOMATOSIS
GALLBLADDER CARCINOMA
REFERENCES
 1
ANATOMY
 GALLBLADDER ANATOMY
● Pear shaped
● Fossa formed by the junction of left and right
lobes
GALLBLADDER ANATOMY
● Fundus
○ frequently causes mass impression
○ Phrygian cap (normal variant)

● Neck – in the porta hepatis and major interlobular

fissure

● Spiral valves of Heister – small folds in the

cystic duct
GALLBLADDER ANATOMY
 GALLBLADDER ANATOMY

Normal Gallbladder:
○ Easily visualized
○ Well distended with bile (at least 4h fast)
○ Wall thickness: </= 3mm
○ Lumen: filled with bile free of particulate debris; fluid density
 GALLBLADDER ANATOMY
Hydropic (Enlarged) Gallbladder: Contracted Gallbladder:
○ >5 cm diameter ● <2cm diameter
 2
IMAGING
MODALITIES
Gallbladder
PLAIN RADIOGRAPH
• Gallstones (10-15%)

• Porcelain Gallbladder

• Emphysematous
Chlolecystitis
PLAIN RADIOGRAPH
• Gallstones (10-15%)

• Porcelain Gallbladder

• Emphysematous
Chlolecystitis
PLAIN RADIOGRAPH
• Gallstones (10-15%)

• Porcelain Gallbladder

• Emphysematous
Chlolecystitis
ULTRASOUND
• Preferred for gallstones (all types)
• No ionizing radiation
CHOLESCINTIGRAPHY (NUCLEAR
MEDICINE)
• Aminodiacetic acid (IDA)

• Patency of cystic and

common bile ducts

• Acute Cholecystitis

• Excellent physiologic
information but limited
anatomic detail
CT vs
MRI
 3
DISEASES
 GALLSTONES

● 85%: Predominantly cholesterol

● 15% Predominantly bilirubin (Pigment stones)
● 10%: laminated or faceted calcifications

MOST COMMON:
● Women (4:1)
● Patients with hemolytic anemia
● Diseases of ileum
● Cirrhosis
● Diabetes Mellitus

IMAGING:
● 95% by Ultrasound
● 80-85% by CT Scan
 GALLSTONES
● CT
○ Vary in attenuation from fat to calcium
density
○ Missed because of size or volume

low-attenuation floating gallstones

 GALLSTONES
● Contrast studies, MRCP, and T2
weighted MR

- as “filling defects” - rounded or faceted dark objects within

high-density bile
 GALLSTONES

● Differential Diagnosis
1. Sludge balls or tumefactive biliary
sludge
2. Cholesterol polyps
3. Adenomatous polyps
4. Gallbladder carcinoma
5. Adenomyomatosis
 GALLSTONES

● Differential Diagnosis
1. Sludge balls or tumefactive biliary
sludge
2. Cholesterol polyps
3. Adenomatous polyps
Cholesterol polyps
4. Gallbladder carcinoma ● Common
● Benign
5. Adenomyomatosis
● Accumulation of trigycerides and cholesterol in macrophages in
GB wall
● No clinical significance
● Polyps 5mm or less – routinely dismissed as benign cholesterol
polyps
 GALLSTONES

● Differential Diagnosis
1. Sludge balls or tumefactive biliary
sludge
2. Cholesterol polyps
3. Adenomatous polyps
4. Gallbladder carcinoma
Adenomatous polyps
5. Adenomyomatosis ● Potentially premalignant
● Found in specimens >10 mm
● Recommendation to follow at 6-12 mos intervals if polyp is 5-10mm
○ Theory of adenoma-to-carcinoma development
 ACUTE CHOLECYSTITIS
● Gallstone obstructing the cystic duct
(90%)

● Acalculous cholecystitis

● Diagnostic: Ultrasound + clinical

assessment
● 3 findings:
○ 1. Cholelithiasis
○ 2. edema of gallbladder wall seen
as a band of echolucency
○ 3. positive sonographic Murphy
sign
 ACUTE CHOLECYSTITIS

● Scintigraphy
- Normal: gallbladder demonstrates
progressive accumulation of
radionuclide activity over 30 minutes
to 1 hour following injection

- Diagnostic: obstruction of the cystic

duct with nonvisualization of the
gallbladder
- Delayed images taken at 4
hours postradionuclide
injection
 ACUTE CHOLECYSTITIS
● CT
o gallstones, distended gallbladder, thickened
gallbladder wall, subserosal edema,
o high-density bile
o intraluminal sloughed membranes,
o inflammatory stranding in pericholecystic fat,
pericholecystic fluid,
o blurring of the interface between gallbladder
and liver
o prominent arterial phase enhancement of the
liver adjacent to the gallbladder
 ACUTE CHOLECYSTITIS

● MR
o gallstones, often impacted in the neck
o wall thickening (>3 mm) with edema
o distended gallbladder
o pericholecystic fluid
 ACUTE CHOLECYSTITIS

Acalculous Cholecystitis
- due to gallbladder wall ischemia
or direct bacterial infection

- Risk factors: Biliary stasis

○ lack of oral intake
○ posttrauma, postburn,
postsurgery
○ total parenteral nutrition

● Ultrasound
- distended tender gallbladder with
thickened wall but without stones
 ACUTE CHOLECYSTITIS

Sludge
- Thick particulate matter in highly
concentrated bile
- Calcium bilirubinate
- Cholesterol crystals

- May be in a normal patient

- Presence is not a definitive evidence of

gallbladder disease
 ACUTE CHOLECYSTITIS

Sludge
US: Echodense
CT: high attenuation bile
MR: layering of bile of
different signal
 COMPLICATIONS OF ACUTE
CHOLECYSTITIS
GALLBLADDER EMPYEMA

- Distended with pus

- Diabetic

- Abdominal abscess: rapid progression

 COMPLICATIONS OF ACUTE
CHOLECYSTITIS
GANGRENOUS CHOLECYSTITIS

- Presence of necrosis of gallbladder wall

- At risk for gallbladder perforation

- Findings:
- Mucosal irregularity
- Asymmetric thickening of GB wall
 COMPLICATIONS OF ACUTE
CHOLECYSTITIS
PERFORATION OF GALLBLADDER

- Life threatening in 5-10%

- Mortality: 24%

1. Pericholecystic abscess (liver)

2. Generalized peritonitis
3. Biliary-enteric fistula
 COMPLICATIONS OF ACUTE
CHOLECYSTITIS
EMPHYSEMATOUS CHOLECYSTITIS

- Infection with gas forming organisms

- E. coli or C. perfringens
- 40% Diabetic

Xray or CT:
- Gas is demonstrated within the wall or within the
lumen of the gallbladder

Ultrasound:
- Intramural gas has an arc-like configuration
difficult to differentiate from calcification and
porcelain gallbladder
 COMPLICATIONS OF ACUTE
CHOLECYSTITIS

MIRIZZI SYNDROME

● biliary obstruction from a gallstone in the cystic

duct eroding into the adjacent common duct
and causing an inflammatory mass that
obstructs the common duct

● Diagnostic: Stone at the junction of the cystic

duct and the CHD
 CHRONIC CHOLECYSTITIS
● Gallstones and chronic gallbladder inflammation
● Clinical presentation:
○ Recurrent attacks of RUQ pain and biliary colic

● Imaging findings:
● Gallstones
● Thickening of gallbladder wall
● Contraction of gallbladder lumen
● Delayed visualization on cholescintigraphy
● Poor contractility
CHRONIC CHOLECYSTITIS
● VARIANTS:

1. Emphysematous Cholecystitis
CHRONIC CHOLECYSTITIS
● VARIANTS:

2. Porcelain Gallbladder
- Dystrophic calcification in the wall of
an obstructed and chronically inflamed
gallbladder

- 90% – associated with gallstones

- 10-20% risk gallbladder CA

CHRONIC CHOLECYSTITIS
● VARIANTS:

3. Milk of Calcium bile (Limy bile)

- associated with an obstructed cystic
duct, chronic cholecystitis, and
gallstones

- Particulate matter with a high

concentration of calcium compounds is
precipitated in the bile
CHRONIC CHOLECYSTITIS
● VARIANTS:

4. Xanthogranulomatous Cholecystitis
- Nodular deposits of lipid laden macrophages
in gallbladder wall and proliferative fibrosis
- Difficult to differentiate with GB Carcinoma
■ Preservation of linear enhancement of
the mucosa on postcontrast MR

- Imaging findings:
o Marked wall thickening 2 cm
o Fat density nodules
o Narrowing of the lumen
 THICKENING OF THE GALLBLADDER
WALL
● Wall thickness on the hepatic aspect of gallbladder > 3 mm in patients who have fasted at
least 8 hours

● Conditions:

● Acute and Chronic Cholecystitis

● Hepatitis
● Portal venous hypertension
● Congestive heart failure
● AIDS
● Hypoalbuminemia
● Gallbladder carcinoma
 ADENOMYOMATOSIS

● Benign
● Wall thickening by hyperplasia of the
mucosa and smooth muscle
● Coexisting gallstones

● Diagnostic: Ultrasound
○ Rokitansky-Aschoff sinuses:
Outpouchings of mucosa into or
through the muscularis
○ “Comet-tail” reverberation artifacts
 ADENOMYOMATOSIS
● MRCP
○ “pearl necklace” appearance

● CT
● Wall thickening with tiny cystic spaces
 GALLBLADDER CARCINOMA

● Tumor of elderly women >60

years

● F:M ratio 4:1

● Clinical Presentation:
● Pain, anorexia, weight loss,
jaundice

● Risk factor:
● Porcelain gallbladder

● Poor prognosis
 GALLBLADDER CARCINOMA

● Imaging findings:
a. Intraluminal soft tissue mass
b. Focal or diffuse thickening of the
gallbladder wall
c. Soft tissue mass replacing the gallbladder
d. Gallstones
e. Extension of tumor into the liver, bile
ducts, and adjacent bowel
f. Dilated bile ducts
g. Metastases to periportal and
peripancreatic lymph nodes and liver