Focal Vs Diffuse Gall
Bladder Wall Thickening
Objectives
• Normal GB wall Appearance
• Causes Of focal GB wall thickening
• Causes of diffuse GB wall thickening
• Appea...
Gall Bladder
• Normal wall thickness < 3mm
• The normal gallbladder wall appears as a
pencil-thin echogenic line at sonogr...
LEFT: US of a normal gallbladder after an overnight fast shows
the wall as a pencil-thin echogenic line (arrow).RIGHT: US ...
The normal gallbladder wall is usually perceptible at CT
as a thin rim of soft-tissue density that enhances after
contrast...
Thickened gallbladder wall
• Thickening of the gallbladder wall is a
relatively frequent finding at diagnostic
imaging stu...
LEFT: US in a 59-year-old woman with acute cholecystitis shows the
layered appearance of a thickened gallbladder wall, wit...
Focal Wall Thickening
• Polyps
• Adenomyomatosis
• Carcinoma
• Xanthogranulomatous cholecystitis
• Metastasis
• Chronic ch...
Polyps/ Cholesterolosis
• A condition in which triglycerides, cholesterol
esters and cholesterol precursors are
deposited ...
• Sometimes referred to as “Strawberry
gallbladder”
• Minority of cases are of polypoid variety
• Cholesterol polyps are “...
• Do not acoustic shadowing
• Do not exhibit postural movement
• Other less common types of polyps are
adenoma
papilloma
l...
• Polyps
< 5mm – no further evaluation
5-10mm – monitoring
> 10mm – should be removed
• As the polyp enlarges – risk of
ma...
Large Fibrous Polyps of the Gallbladder Simulating
Gallbladder Carcinoma
GB Polyp fixed to the ventral wall of the GB
Diffuse Wall
Thickness
• CAUSES
• Biliary Causes
1.Cholecystitis
2.Adenomyomatosis
3.Cancer
4.AIDS cholangiopathy
5.Sclero...
• NON BILIARY CAUSES
1.Hepatitis
2.Pancreatitis
3.Heart Failure
4.Hypoproteinemia
5.Cirrhosis
6.Portal hypertension
7.Lymp...
Cholecystitis
• Acute
• Chronic
• Acalculous
• Xanthogranulomatous
Acute cholecystitis
• Fourth most common cause of hospital
admissions for patients presenting with an
acute abdomen
• It i...
Signs of Acute cholecystitis
• Thickened gall bladder wall
• Obstructing gallstone
• Hydropical dilatation of the gallblad...
Acute calculous cholecystitis.
Transverse sonogram at the spot of maximum tenderness shows a non-
compressible hydropicall...
Chronic cholecystitis
• Chronic cholecystitis is a term used clinically
to refer to symptomatic gallbladder stones
that ca...
Chronic cholecystitis. Longitudinal sonogram of the gallbladder shows
slight wall thickening (arrow) and an intraluminal n...
Acalculous cholecystitis
• Mainly occurs in critically ill patients,
(Major surgery, Major trauma,extensive burns)
• Due t...
Acalculous cholecystitis
PITFALL
• Because in critically ill patients gallbladder
abnormalities are frequently found
secon...
74-year-old man with acute acalculous cholecystitis.
LEFT: US at the spot of maximum tenderness shows mural thickening of
...
Xanthogranulomatous
cholecystitis
• Unusual variant of chronic cholecystitis,
• Characterized by a Destructive
inflammator...
• Imaging studies show marked gallbladder
wall thickening, often containing intramural
nodules that are hypoechoic at sono...
Xanthogranulomatous cholecystitis. LEFT: US shows marked wall
thickening with intramural hypoechoic nodules (arrowheads), ...
Contrast-enhanced CT shows a deformed and thickened gallbladder wall containing
hypoattenuating nodules .
These represent ...
Adenomyomatosis
• Benign condition that requires no specific
treatment,
• Incidental finding in upto 9% of
cholecystectomy...
• The sonographic finding of cholesterol crystals,
shown as 'comet-tail' reverberation artifacts,
within a thickened wall ...
Four types of gallbladder
adenomyomatosis
• A. Annular type.
• B. Segmental type, which describes an
annular or segmental ...
• Exclusion of gallbladder cancer may be
most problematic in segmental and focal
cases. Focal adenomyomatosis may
appear a...
Diffuse adenomyomatosis of gall bladder. These gall bladder
ultrasound images show multiple echogenic foci within the
GB w...
Gallbladder
Adenomyomat
osis: Axial CT
of the
abdomen with
oral and IV
contrast shows
focal
thickening of
the gallbladder
...
Oral cholecystogram and
MRCP
• Historically oral cholecystograms were performed,
however due to low sensitivity and a high...
Rokitansky-Aschoff
sinuses shown on
the after fatty meal
film at
cholecystography
Stricture is also
present.
Fundal nodule of
adenomyomatosis
before and after
gallbladder
contraction.
MRI
• The pearl necklace sign alludes to the
characteristically curvilinear arrangement
of multiple rounded hyperintense
i...
pearl necklace sign
• It represents the contrast / fluid filled
intramural mucosal diverticula
(Rokitansky-Aschoff sinuses...
coronal T2
Gallbladder carcinoma
• Fifth most common malignancy of the GIT
• found incidentally in 1% to 3% of cholecystectomy
specim...
Associated findings
• -- invasion of adjacent structures,
• --secondary bile duct dilatation, and
• --liver or nodal metas...
Pathology
• 90% are adenocarcinoma ,
• 5% are squamous carcinomas and
• 5% is anaplastic carcinomas.
• They appear as gall...
SPREADS
80% are detected after direct invasion or portal
node involvement.
• Local direct invasion into the hepatic bed,
•...
Investigations
• Abdominal ultrasound scan : may shows
gallbladder wall thickening or a mass filling the
gallbladder , whi...
Gall bladder carcinoma with portal vein and biliary tree infiltration
Abnormal gallbladder with stones and sludge and a thickened irregular
wall. Liver metastases and tumor thrombus in the lef...
Portal Venous phase--- GB Ca
This sagittal sonogram image demonstrates heterogeneous thickening of
the gallbladder wall (arrows), found to be primary p...
Primary Sclerosing
Cholangitis
• Etiology –unknown
• Inflammatory process affecting intra
and extra hepatic ducts
• Presen...
• Multifocal stricture of bile duct
• 86% will have both intra and extra hepatic
involvement
Characteristic intrahepatic strictures of sclerosing
cholangitis.
Characteristic stricturing of sclerosing cholangitis involving
the intra- and extrahepatic biliary system.
AIDS cholangiopathy
• Obliterative cholangiopathy due to
oppurtunistic infection of the bile duct by
-CMV
-Pnemocystis car...
• NON BILIARY CAUSES
1.Hepatitis
2.Pancreatitis
3.Heart Failure
4.Hypoproteinemia
5.Cirrhosis
6.Portal hypertension
7.Lymp...
Edematous thickening of the gallbladder wall in a patient with
cardiac failure and ascites.
Edematous thickened gallbladder wall in a patient with cardiac failure
Edematous thickened gallbladder wall in a patient with
hepatitis
Hepatitis with a thickened gallbladder wall
Gallbladder wall thickening in a patient with a sepsis and
hepatosplenomegaly
The image above was taken in a patient with cirrhosis, chronic ascites,
and no acute complaints of upper abdominal pain.
How to differentiate b/w
cholecystitis and non biliary
causes
??
How to differentiate b/w
cholecystitis and non biliary
causes
• Clinical correlation
• Presence and absence of sonographic...
Conclusion
• GB wall thickness can be
--Focal
--Generalized
• Both biliary and non-biliary causes can
result in increase i...
THANK YOU
Focal vs diffuse gall bladder wall thickening
Focal vs diffuse gall bladder wall thickening
Focal vs diffuse gall bladder wall thickening
Focal vs diffuse gall bladder wall thickening
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Focal vs diffuse gall bladder wall thickening

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  • Interestingly non B. edema produces more marked thickening than A. cholecystitis
  • Those were the images of a 49-year-old woman with chronic cholecystitis.
    This patient had fasted overnight, so the wall-thickening does not represent physiologic contraction.
    Correlation of these findings with her clinical history of recurrent colic-like right upper quadrant pain, due to transient gallbladder obstruction, is essential for the diagnosis
  • Interestingly non B. edema produces more marked thickening than A. cholecystitis
  • Focal vs diffuse gall bladder wall thickening

    1. 1. Focal Vs Diffuse Gall Bladder Wall Thickening
    2. 2. Objectives • Normal GB wall Appearance • Causes Of focal GB wall thickening • Causes of diffuse GB wall thickening • Appearances of different conditions • Differentiating points • Pitfalls of GB wall thickening
    3. 3. Gall Bladder • Normal wall thickness < 3mm • The normal gallbladder wall appears as a pencil-thin echogenic line at sonography. • The thickness of the gallbladder wall depends on the degree of gallbladder distention and pseudothickening can occur in the postprandial state.
    4. 4. LEFT: US of a normal gallbladder after an overnight fast shows the wall as a pencil-thin echogenic line (arrow).RIGHT: US in the postprandial state shows pseudothickening of the gallbladder
    5. 5. The normal gallbladder wall is usually perceptible at CT as a thin rim of soft-tissue density that enhances after contrast injection.
    6. 6. Thickened gallbladder wall • Thickening of the gallbladder wall is a relatively frequent finding at diagnostic imaging studies. • A thickened gallbladder wall measures more than 3 mm, typically has a layered appearance at sonography , and at CT frequently contains a hypodense layer of subserosal oedema that mimics pericholecystic fluid.
    7. 7. LEFT: US in a 59-year-old woman with acute cholecystitis shows the layered appearance of a thickened gallbladder wall, with a hypoechoic region between echogenic lines RIGHT: At contrast-enhanced CT the thick-walled gallbladder contains a hypodense outer layer (arrow) due to subserosal oedema
    8. 8. Focal Wall Thickening • Polyps • Adenomyomatosis • Carcinoma • Xanthogranulomatous cholecystitis • Metastasis • Chronic cholecystitis • Tumefactive sludge / Sludge balls
    9. 9. Polyps/ Cholesterolosis • A condition in which triglycerides, cholesterol esters and cholesterol precursors are deposited in lamina propria of GB. • Cause is unknown • Not related to serum lipid level, atherosclerosis, diabetes, cholesterol stones, or hyperconcentration of cholesterol in bile. • Most cases do not produce any detectable change in appearance.
    10. 10. • Sometimes referred to as “Strawberry gallbladder” • Minority of cases are of polypoid variety • Cholesterol polyps are “enlarged papillary fronds filled with lipid laden macrophages” • Attached to the wall by a stalk • “Ball on the wall” • 5mm or less, rarely get bigger than 10mm
    11. 11. • Do not acoustic shadowing • Do not exhibit postural movement • Other less common types of polyps are adenoma papilloma leiomyoma lipoma neuroma
    12. 12. • Polyps < 5mm – no further evaluation 5-10mm – monitoring > 10mm – should be removed • As the polyp enlarges – risk of malignancy increases
    13. 13. Large Fibrous Polyps of the Gallbladder Simulating Gallbladder Carcinoma
    14. 14. GB Polyp fixed to the ventral wall of the GB
    15. 15. Diffuse Wall Thickness • CAUSES • Biliary Causes 1.Cholecystitis 2.Adenomyomatosis 3.Cancer 4.AIDS cholangiopathy 5.Sclerosing cholangitis
    16. 16. • NON BILIARY CAUSES 1.Hepatitis 2.Pancreatitis 3.Heart Failure 4.Hypoproteinemia 5.Cirrhosis 6.Portal hypertension 7.Lymphatic obstruction
    17. 17. Cholecystitis • Acute • Chronic • Acalculous • Xanthogranulomatous
    18. 18. Acute cholecystitis • Fourth most common cause of hospital admissions for patients presenting with an acute abdomen • It is the prime diagnostic concern when a thick-walled gallbladder is found at imaging. • This feature, however, is not pathognomonic and additional imaging signs should be present to support the diagnosis of acute calculous cholecystitis.
    19. 19. Signs of Acute cholecystitis • Thickened gall bladder wall • Obstructing gallstone • Hydropical dilatation of the gallbladder, • A positive sonographic Murphy's sign ( i.e., pain elicited by pressure over the sonographically located gallbladder), • Pericholecystic fat inflammation or fluid • Hyperemia of the gallbladder wall at power Doppler
    20. 20. Acute calculous cholecystitis. Transverse sonogram at the spot of maximum tenderness shows a non- compressible hydropically distended thick-walled gallbladder (arrowheads), with an intraluminal stone and sludge or debris. Contrast-enhanced CT depicts extensive fat inflammation (arrowheads) surrounding the gallbladder (arrow).
    21. 21. Chronic cholecystitis • Chronic cholecystitis is a term used clinically to refer to symptomatic gallbladder stones that cause transient obstruction, leading to a low-grade inflammation with fibrosis . • Correlation of the imaging finding of a stone-containing slightly thick-walled gallbladder with the clinical history is critical.
    22. 22. Chronic cholecystitis. Longitudinal sonogram of the gallbladder shows slight wall thickening (arrow) and an intraluminal non-obstructing stone
    23. 23. Acalculous cholecystitis • Mainly occurs in critically ill patients, (Major surgery, Major trauma,extensive burns) • Due to Increased bile viscosity from fasting and Medication that causes cholestasis. • The imaging features are those of acute cholecystitis, except for the absence of stones whereas gallbladder sludge is usually present.
    24. 24. Acalculous cholecystitis PITFALL • Because in critically ill patients gallbladder abnormalities are frequently found secondary to systemic disease , acalculous cholecystitis can be difficult to diagnose . • In these patients a percutaneous cholecystostomy can be both diagnostic and therapeutic.
    25. 25. 74-year-old man with acute acalculous cholecystitis. LEFT: US at the spot of maximum tenderness shows mural thickening of the gallbladder (arrow) that is completely filled with sludge (asterix) without any stones.RIGHT: Power-Doppler sonography shows hypervascularity of the gallbladder wall (arrowhead), as a supporting sign of inflammation.
    26. 26. Xanthogranulomatous cholecystitis • Unusual variant of chronic cholecystitis, • Characterized by a Destructive inflammatory process with varying proportions of fibrous tissue, inflammatory cells and lipid laden macrophages • Gall stones +/- • Locally invasive
    27. 27. • Imaging studies show marked gallbladder wall thickening, often containing intramural nodules that are hypoechoic at sonography and hypoattenuating at CT, representing abscesses or foci of xanthogranulomatous inflammation. • These features overlap with those of gallbladder carcinoma, making preoperative distinction between these entities often impossible.
    28. 28. Xanthogranulomatous cholecystitis. LEFT: US shows marked wall thickening with intramural hypoechoic nodules (arrowheads), and an intraluminal stone (arrow).RIGHT: Contrast-enhanced CT shows a deformed and thickened gallbladder wall containing hypoattenuating nodules
    29. 29. Contrast-enhanced CT shows a deformed and thickened gallbladder wall containing hypoattenuating nodules . These represent abscesses or foci of inflammation. The lumen contains several stones (arrow).
    30. 30. Adenomyomatosis • Benign condition that requires no specific treatment, • Incidental finding in upto 9% of cholecystectomy specimens Characterized by • 1. Epithelial proliferation, • 2. Muscular hypertrophia and • 3. Intramural diverticula (Rokitansky-Aschoff sinuses), which may segmentally or diffusely involve the gallbladder.
    31. 31. • The sonographic finding of cholesterol crystals, shown as 'comet-tail' reverberation artifacts, within a thickened wall of the gallbladder strongly suggests this diagnosis. • Air may produce a similar artifact, however, patients with emphysematous cholecystitis are usually ill in contrast to those with adenomyomatosis. • MR imaging may be able to differentiate adenomyomatosis from gallbladder carcinoma by depicting Rokitansky-Aschoff sinuses.
    32. 32. Four types of gallbladder adenomyomatosis • A. Annular type. • B. Segmental type, which describes an annular or segmental wall thickening causing stricture that divides the gallbladder lumen into separate interconnected compartments. • C. Fundal type,(adenomyoma) a focal elevated lesion with a central dimple located at the fundus of the gallbladder. • D .Diffuse type, a thickened wall involving the entire gallbladder.
    33. 33. • Exclusion of gallbladder cancer may be most problematic in segmental and focal cases. Focal adenomyomatosis may appear as a discrete mass, known as an adenomyoma.
    34. 34. Diffuse adenomyomatosis of gall bladder. These gall bladder ultrasound images show multiple echogenic foci within the GB wall with V-shaped comet-tail .
    35. 35. Gallbladder Adenomyomat osis: Axial CT of the abdomen with oral and IV contrast shows focal thickening of the gallbladder wall (arrows)
    36. 36. Oral cholecystogram and MRCP • Historically oral cholecystograms were performed, however due to low sensitivity and a high rate of contrast allergies it has now largely been replaced by MRCP which does not rely on contrast opacification of the lumen of the gallbladder. • MRCP would be also to detect : • mural thickening • focal sessile mass • pearl necklace sign (fluid filled intramural diverticula) • hourglass configuration in annular types
    37. 37. Rokitansky-Aschoff sinuses shown on the after fatty meal film at cholecystography Stricture is also present.
    38. 38. Fundal nodule of adenomyomatosis before and after gallbladder contraction.
    39. 39. MRI • The pearl necklace sign alludes to the characteristically curvilinear arrangement of multiple rounded hyperintense intraluminal cavities visualized at T2- weighted MR imaging and MR cholangiopancreatography of adenomyomatosis.
    40. 40. pearl necklace sign • It represents the contrast / fluid filled intramural mucosal diverticula (Rokitansky-Aschoff sinuses) which line up reminiscent of pearls on a necklace. • highly specific (92%) • frequently not seen, • only present in ~ 70% of cases
    41. 41. coronal T2
    42. 42. Gallbladder carcinoma • Fifth most common malignancy of the GIT • found incidentally in 1% to 3% of cholecystectomy specimens. • It is often detected at a late stage of the disease, due to lack of early or specific symptoms. • Gallbladder carcinoma has various imaging appearances, ranging from a - polypoid intra-luminal lesion to -an infiltrating mass replacing the gallbladder, -diffuse mural thickening.
    43. 43. Associated findings • -- invasion of adjacent structures, • --secondary bile duct dilatation, and • --liver or nodal metastases may help in differentiating a carcinoma from acute or xanthogranulomatous cholecystitis . • In absence of these associated findings, it may not be possible to differentiate a carcinoma from xanthogranulomatous cholecystitis.
    44. 44. Pathology • 90% are adenocarcinoma , • 5% are squamous carcinomas and • 5% is anaplastic carcinomas. • They appear as gallbladder wall thickening and induration. • Most common sites are at the fundus and neck of the gallbladder • Pocelain GB and sclerosing cholangitis are predisposing factors
    45. 45. SPREADS 80% are detected after direct invasion or portal node involvement. • Local direct invasion into the hepatic bed, • Lymphatic spread into the cystic nodes, hiatal nodes and then to the superior and posterior pancreaticoduodenal nodes and the periaortic nodes. • Blood borne spreads via the portal vein to the liver • 5 yr survival is < 20%
    46. 46. Investigations • Abdominal ultrasound scan : may shows gallbladder wall thickening or a mass filling the gallbladder , which would be suggestive of malignancy. • CT or MRI scan : show a mass in the region of gallbladder. • Arteriographic CT portogram ; Where contrast is injected into the superior mesenteric artery , allows accurate measurements of the extent of the disease and is resectability.
    47. 47. Gall bladder carcinoma with portal vein and biliary tree infiltration
    48. 48. Abnormal gallbladder with stones and sludge and a thickened irregular wall. Liver metastases and tumor thrombus in the left portal vein.
    49. 49. Portal Venous phase--- GB Ca
    50. 50. This sagittal sonogram image demonstrates heterogeneous thickening of the gallbladder wall (arrows), found to be primary papillary adenocarcinoma
    51. 51. Primary Sclerosing Cholangitis • Etiology –unknown • Inflammatory process affecting intra and extra hepatic ducts • Presentation and course is highly variable • May present in infancy or old age • C/C --- cholestasis • Predisposition ---to bile duct cancer
    52. 52. • Multifocal stricture of bile duct • 86% will have both intra and extra hepatic involvement
    53. 53. Characteristic intrahepatic strictures of sclerosing cholangitis.
    54. 54. Characteristic stricturing of sclerosing cholangitis involving the intra- and extrahepatic biliary system.
    55. 55. AIDS cholangiopathy • Obliterative cholangiopathy due to oppurtunistic infection of the bile duct by -CMV -Pnemocystis carinii -Cryptosporidium • Presentation is similar to PSC • C/C abd. Pain and cholangitis • Tx .. Endoscopic sphincterotomy
    56. 56. • NON BILIARY CAUSES 1.Hepatitis 2.Pancreatitis 3.Heart Failure 4.Hypoproteinemia 5.Cirrhosis 6.Portal hypertension 7.Lymphatic obstruction
    57. 57. Edematous thickening of the gallbladder wall in a patient with cardiac failure and ascites.
    58. 58. Edematous thickened gallbladder wall in a patient with cardiac failure
    59. 59. Edematous thickened gallbladder wall in a patient with hepatitis
    60. 60. Hepatitis with a thickened gallbladder wall
    61. 61. Gallbladder wall thickening in a patient with a sepsis and hepatosplenomegaly
    62. 62. The image above was taken in a patient with cirrhosis, chronic ascites, and no acute complaints of upper abdominal pain.
    63. 63. How to differentiate b/w cholecystitis and non biliary causes ??
    64. 64. How to differentiate b/w cholecystitis and non biliary causes • Clinical correlation • Presence and absence of sonographic Murphy’s sign • Associated signs e.g. Pulsatile portal venous flow in heart failure Portal HTN & nodular liver in Cirrhosis
    65. 65. Conclusion • GB wall thickness can be --Focal --Generalized • Both biliary and non-biliary causes can result in increase in wall thickness • Clinical correlation is important
    66. 66. THANK YOU
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